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SURGICAL      DISEASES 


OF   THE 


OVARIES  AND  FALLOPIAN  TUBES, 

INCLUDING  TUBAL   PREGNANCY. 


-    --■•V'^-' 


Plate  I. — A  Composite  Drawino;  of  the  Microscopical  Appearance  of  the  Dermoid 

sketched  in  Fig.  23.     {Trans.  Obstet.  Soc.) 

A,  All  epithelial  pearl  in  section  ;  H,  glandular  tissue;  C,  developing  hair'; :  n,  ■■ 

developing  tooth  ;  U,  sweat-glands  in  section. 


SURGICAL  DISEASES 


OF   THE 


Ovaries  and  Fallopian  Tubes, 


INCLUDING 

TUBAL     PREGNANCY, 


BY 


/ 


J.     BLAND     SUTTON,     F.R.C.S. 

ASSISTANT-SURGEON    TO    THE    MIDDLESEX    HOSPITAL  ; 

LATE    HUNTERIAN    I'ROFESSOR,    AND    ERASMUS    WILSON    LECTTKER, 

ROV'AL    COLLEGE    OF    SURGEONS,    ENGLAND. 


WITH  im    EXGRAVIXGS   AXD    5    COLOURED    PLATES. 


PHILADELPHIA  : 

LEA     BROTHERS     &     CO., 

l^Late  Henry  C.   Lea's  Son  of  Co.\ 
PUBLISHERS. 


Established     17  S  5 


PREFACE. 


The  literature  relating  to  Surgical  Diseases  of 
the  Ovaries  displays  a  notorious  amount  of 
egoism.  Nearly  every  treatise  devoted  to  this 
subject  is  mainly  a  record  of  personal  experi- 
ence. In  some  instances  self-consciousness  has 
been  carried  to  such  a  degree  that  the  books 
consist  of  little  else  than  the  clinical  histories  of 
patients  coming  under  the  observation  of  their 
authors. 

In  the  present  work  a  different  plan  has  been 
followed,  for  though  the  book  is  largely  based  on 
personal  investigation,  full  justice  is  done  to  the 
original  work  of  other  surgeons.  This  is  a 
method  rarely  followed  by  those  engaged  in  that 
section  of  surgical  craft  known  by  the  grandilo- 
quent term — Gynaecology. 

Here  and  there  use  has  been  made  of  facts 
furnished  by  comparative  patholog}^  especially 
in  elucidating  the  nature  of  ovarian  hydrocele, 
and    in    relation    with    menstruation    and     tubal 

347549 


vi  Diseases  of  the  Ovaries,  etc. 

pregnancy.  Any  attempt  to  put  the  pathology 
of  extra-uterine  gestation  on  a  sound  basis  is 
rendered  difficult  by  the  large  number  of  erroneous 
assertions,  or,  as  Jevons  styled  them,  false  facts, 
which  abound  in  the  literature  of  this  important 
subject  ;  they  have  retarded  progress  because  it 
is  often  impossible  to  prove  the  falsity  of  records 
relating  to  specimens  no  longer  in  existence. 

For  some  years  Mr.  Lawson  Tait  has  been 
slowly  planning  the  overthrow  of  the  ridiculous 
notions  taught  concerning  the  pathology  of  extra- 
uterine pregnancy.  Although  fertile  in  critical 
methods,  by  which  he  has  undermined  these 
opinions,  he  has  never  objectively  demonstrated 
the  reality  of  his  conceptions  in  such  a  way  as  to 
cause  an  unequivocal  explosion.  In  the  third 
section  of  this  book  I  have  attempted  to  assist 
in  this  useful  iconoclastic  endeavour.  The  time 
is  not  far  distant  when  even  teachers  of  mid- 
wifery will  wonder  how  they  could  ever  have 
believed  that  an  impregnated  ovum  would  grow 
upon  the  peritoneum. 

Much  care  has  been  expended  on  the  illus- 
trations ;  all,  with  the  exception  of  sixteen 
(the  sources  of  which  are  duly  acknowledged), 
are    original,    and    produced    under    my    personal 


Preface.  vii 

superintendence.  In  most  I  have  introduced  the 
plan  of  substituting  words  for  reference  letters. 
This  is  a  novelty  in  surgical  writing,  but  it  has 
been  so  useful  to  anatomical  authors  that  I  feel  no 
hesitation  in  adopting  it. 

J.    BLAND     SUTTON. 

Queen  Anne  Street^ 

Cavendish  Square,   IF. 
Oc/oder,    1S91. 


CONTENTS, 


\Hvt   X, 


DISEASES    OF   THE    OVARIES. 

CHAPTER  PAGE 

I.  Sex  ;  THE  Genital  Gland  of  the  Female  ; 
Secondary  Sexual  Characters  ;  Men- 
struation     I 

II.     Cystic  Corpora  Lutea  ;   Apoplexy  of  the 

Ovary  ;  Ovarian  Concretions        .        .     14 

III.  ^Malformations,  Misplacement,  and  Atro- 

phy OF  ihe  Ovaries  .        .        .        .22 

IV.  The  Pelvic  Peritoneum        .        .        .        -36 
V.     OoPHORiTic  Cysts 44 

VI.     Ovarian  Dermoids 57 

VII.  Solid  Tumours  of  the  Ovary      .        .        -71 
VIII.  Ovarian  Tumours  in  Infancy  and  Child- 
hood     83 

IX.  Paroophoritic  Cysts   and  Warty  Ovaries    93 

X.     Parovarian  Cysts 104 

XI.     Ovarian  Hydrocele iii 

XII.  Secondary  Changes  in  Ovarian  Tumours, 

iNFLAItlMATION,     SUPPURATION,     AND     AD- 
HESIONS   123 

XIII.  Axial  Rotation      ......   135 

XIV.  Pressure  Effects 147 

XV.     The  Diagnosis  of  Ovarian  Tumours  .        .   163 


Diseases  of  tjie  Ovaries,  etc. 

CHAl'TER  I'AC.E 

XVL     This    Differential  Diagnosis  of  Ovarian 

Tumours 183 

XVII.     The  Differential  Diagnosis   of   Ovarian 
Tumours — Morbid    Conditions    of   the 

Broad  Ligament 203 

XVIII.     Treatment  of  Ovarian  Tumours        .         .  214 


fart  11. 

DISEASES    OF   THE   FALLOPIAN    TUBES, 

XIX.     The  Fallopian  Tubes 223 

XX.     Salpingitis  and  its  Effects:  Pyosalpinx    235 
XXI.     Tubo-Ovarian     Abscess  —  Hydrosalpinx — 

HiBMATOSALPINX 250 

XXII.     Catarrhal    Salpingitis    in    Relation    to 

Adenoma  of  the  Neck  of  the  Uterus   265 

XXIII.  Tuberculosis   and  Actinomycosis   of  the 

Ovary  and  Fallopian  Tube    .        .        .  272 

XXIV.  Neoplasms  of  the  Fallopian  Tube    .        .  2S0 
XXV.     The  Diagnosis  of  Salpingitis     .        .        .  289 

XXVI.     The      Treatment     of     Salpinchtis      and 

Oophoritis 301 


fart    XXXx 

TUBAL   PREGNANCY. 


XXVII.     Tubal  Pregnancy 307 

XXVIIT.     Primary  Rupture  of  the  Gestation  Sac  .  321 
XXIX.     Tubal  Abortion      ....  .  326 


Contents. 


XI 


CHAPTER 

XXX. 

XXXI. 

XXXII. 

XXXIII. 


XXXIV. 

XXXV. 

XXXVI. 

XXXVII. 


Tubal    Gestation.      The    Placenta    and 
•     Decidua;  Secondary  Rupture        .        .  333 
Turo-Uterine  Gestation      ....  348 

Cornual  Pregnancy      354 

Twin  Gestation  :  One  Fcejus  Intra-  the 
Other  Extra  -  Uterine  —  Repeated 
Extra-Uterine  Gestation  .  .  .  364 
Retention  of  the  Fcetus  ....  372 
Tubal  Gestation  in  the  Lower  Mammals  381 
The  Diagnosis  of  Tubal  Pregnancv  .  .  397 
The  Treatment  of  Tubal  Gestation         .  416 


fart    lYx 

METHODS    OF    PERFORMING    OPERATIONS    FOR 
OVARIAN  AND  TUBAL  DISEASE. 


XXXVIII.     Ovariotomy      .        .        . 

XXXIX.     Oophorectomy 

XL.     Irrigation  and  Drainage     . 
XLI.     The   Risks  and   Sequel/e  of  Ovariotom\ 
and  Allied  Operations   . 
XLII.     The    Effects    of    the    Removal    of    th 
Ovaries    on     the    Secondary    Sexuai 
Characters  of  Women 

Index  to  Names 

Index  to  Subjects      .        .         ,       ■ . 


428 

447 

452 

459 


475 
489 
492 


LIST     OF     ILLUSTRATIONS. 


COLOURED     PLATES. 

Microscopic  Appearance  of  Sections  from  a  Dermoid       Frontispiece 
An  Ovarian  Myoma  .         ....        To  face  page  74 

Echinococcus  Colonies  in  the  Broad  Ligament  ,,         ,,     188 

Microscopic   Changes    of    the   Tubal    Mucous    Membrane   in 

Salpingitis  .         .         .         .  .         .To  face  page.  242 

A  Tubal  Mole  (Magnified)        .         .         .         .  ,,         ,,     320 

WOODCUTS. 

PAGE 

Ovary  of  a  Woman   twenty- three  years   old,   with    Fallopian 

Tube  in  position        ........       2 

Ovary  from  a  Woman  forty  years  of  age   .....       3 

Section  of  Ovary  showing  ripening  Follicles     ....       4 

Microscopical  appearance  of  a  transverse  section  of  the  Fal- 
lopian  Tube    of  a  Macaque    Monkey    [Macaais    rhesus) 
during  Menstruation  ........       9 

Apoplexy  of  the  Ovary     ....... 

Ovary  with  Cysts  containing  Concretions 
Genital  Organs  of  a  pseudo-hermaphrodite 
Uterus,  Tubes,  and  Ovaries  of  an  Infant  one  month  old    . 
Ovary  and  Tube  of  a  Woman  sixty-eight  years  of  age 
Atrophied  and  Crenate  Ovary  from  a  Woman  thirty-nine  years 
of  age        ......... 

Diagram  representing  the  Cyst  Regions  of  the  Ovary 
Incipient  Oophoritic  Cyst,  etc.  ..... 

Oophoritic  Cyst        ........ 

Section  of  Mucous  Membrane  from  an  Ovarian  Cyst 


18 
20 
26 

31 

32 

34 
44 
45 
47 
48 


List  of  Illustrations.  xiii 

I'AGE 

Unilocular  Ovarian  Dermoid 49 

Human  Ovary  in  section  showing  a  Mullilocular  Cyst  in  an 

early  stage         .         .         .         .         •         •         •         •         •     5^ 
Portion    of  an    Ovarian    Adenoma   showing    the  varieties    of 

Loculi 53 

Ovarian  Adenoma  presenting  a  Cutaneous  Clump  with  a  tuft 

of  hair       ..........     54 

Transverse  section  of  an  Ovarian  Tumour  from  a  Mare  .  .  55 
Ovarian  Dermoid,  with  a  pseudo-mamma         .         .         .         -59 

Mammiferous  Dermoid 60 

Histological  Characters  of  the  Ovarian  Mamma  described  by 

Velits 61 

Ovarian  Dermoid      .........     62 

Ovarian   Teeth  :    showing    Canines,   Bicuspidate,   and    Multi- 
cuspidate  Teeth         ........     64 

Microscopic  characters  of  a  ]Multicuspidate   and    Bicuspidate 

Ovarian  Tooth  ........     65 

Ovarian  Dermoid  containing  Brain-matter        .         .         .         .66 

Ovarian  Dermoid  from  a  Pregnant  Woman      .         .         .         .68 

Ovarian  Fibro-myoma 73 

Section  of  an  Ovary  with  secondary  deposits  of  Melanotic  Cancer  79 
Cancer  deposits  in  Ovary  ;  secondary  to  Cancer  of  Breast  .  80 
Uterus  and  Ovaries  of  a  Child  two  months  old  .  .  -83 
Multilocular  Ovarian  Cyst  from  a  Foetus  born  at  full  time  .  84 
Tumour  of  the  Ovary  from  a  seven  months'  Foetus  .         ,  -85 

Histological  Characters  of  the  Tumour  of  the  Ovary  of  a  seven 

months'  Foetus  ........ 

Microscopical  Characters  of  an  Alveolar  Oophoroma 
Paroophoritic  Cyst .         .         .         .         .         .         .  •        . 

Ruptured  Paroophoritic  Cyst  (right  half  of  the  specimen) 

Ruptured  Paroophoritic  Cyst  (left  half  of  specimen) 

Papillary   Cyst   growing   between   the    layers   of    the    Broad 

Ligament,  near  the  Tubo-ovarian  Ligament 
Warty  (not  Paroophoritic)  Cysts  of  the  Ovary  .         .         •         • 
Warty  Cyst,  burrowing  between  the  layers  of  the  Mesosalpinx 

along  the  Tubo-Ovarian  Ligament    .  .         .  •         •    102 


86 
91 
94 
96 

97 
99 

lOI 


Xiv  D/S EASES    OF    THE    OrAKlES^    ETC. 


I'AGE 

1^5 


1 06 

109 
112 
"3 

114 

"5 
116 
117 
118 
119 
1 20 

125 
126 


The  Parovarium  (semi-diagrammatic)       .... 

A  Cyst  of  the  Parovarium  showing  its  relation  to  Ovary  and 

Tube        ......  ... 

Ovary  and  Stump  of  a  Fallopian  Tube,  left  after  Axial  rotation 

ending  in  complete  detachment    of  a  Parovarian  Cyst 
Ovarian  Plydrocele  ........ 

Ovarian  Hydrocele  (Dr.  Walter's  specimen)     . 

The  Ovarian  Sac  or  Recess  on  the  posterior  aspect  of  the 

Broad  Ligament  (human) 

Transverse  section  of  the  Ovary  and  Ovarian  Sac  of  a  Mouse 

Ovarian  Sac  of  a  Baboon 

Ovarian  Sac  of  a  Porcupine      ...... 

Ovarian  Hydrocele  from  a  Mare       ..... 

Ovarian  Hydroceles  in  a  Guinea-pig         .... 

Ovarian  Hydrocele  ....... 

Ovarian  Dermoid  and  Pyosalpinx 

Small  adherent  Ovarian  Cyst  ...... 

Portion  of  the  wall  of  an  Ovarian  Cyst,  with  shaggy  Adhesions    132 
Ovarian    Cyst  which    had    become  detached  from   its  uterine 

connections,  probably  by  torsion       .         .         .         .         .141 
Oophoritic   Cyst   with  a  perforated  Septum  between  its  two 

Loculi      .         .         .         .         .         . 

Hydatid  Cyst  in  the  Pelvis      .  .         .         .         .         . 

Kidney  occupying  the  hollow  of  the  Sacrum     . 

Myoma  of  the  Broad  Ligaments       ..... 

Broad  Ligament  Myoma  ...... 

Sagittal  Section  of  the  parts  involved  in  the  so-called  Anterior 

Perimetritis      .         .         .         .  .  .         . 

Fallopian  Tube  with  an  Accessory  Ostium 
Pedunculated  Accessory  Fimbriae     ..... 

Two  Accessory  Ostia  on  one  Fallopian  Tube    . 

Pedunculated    Cyst   from  the    Parovarium,    lying  athwart   the 

Tube         ,..,..... 

Simple  forms  of  Glands  ....... 

Transverse    Section   of    the    Fallopian    Tul)e    of    a    Macaque 

Monkey  .    .    .    ,    ,    ,    ,    ,    ,    -231 


149 
187 
191 
207 
208 

212 
226 

228 
228 

22S 
230 


List  of  Illustrations.  w 

I'AGE 

Recess   of  the  Tubal  Mucous  Membrane  of  the  raiiolian  Deer 

{Cervus  cldi)     .  .  .  .         " 232 

Transverse  .Section  of  the  Fallopian  Tube  of  a  Woman     .  .   233 

Section  of  a  Uterus  from   which   a  Gangrenous   Myoma  had 

been  removed  .  .  ......   237 

Salpingitic  closure  of  the  Ostium      ......  239 

Salpingilic  closure  of  the  Ostium      ......   239 

Salpingitic  closure  of  the  Ostium     ......   239 

Transverse  section  of  an  Inflamed  Tube  and  Mesosalpinx  .   240 

Aggressive  Cells  from  the  Mucous  Membrane  of  a  chronically 

inflamed  Fallopian  Tube  .......   243 

Large  Pyosalpinx    .........  245 

Two  Legume-shaped  Cysts  supposed  to  be  Fallopian  Tubes  .  246 
Uterus  of  a  Ewe  distended  with  Mucus  :  Hydrometra       .  .  247 

The  two  supposed  Fallopian  Tubes  restored  to  their  probable 

natural  relationship  ........   248 

Tubo-Ovarian  Abscess,  secondary  to  Gonorrhoea      .         .         .251 
Tubo-Ovarian  Abscess     ........   252 

Hydrosalpinx  .........  254 

Uterus  of  a  Harridan       .         .         .         .         .         .         ,         .  255 

Hydrosalpinx  with  twisted  Pedicle  ......  257 

Hydrosalpinx  .........   260 

Pedunculated  Adenomata  of  the  Cervical  Canal  .  .  .  266 
Cervix  uteri  of  a  Macaque  Monkey,  with  Adenoma  .  .  .  268 
Sagittal    Section  of  the  Cervix  uteri   of  a  Macaque    Monkey 

aftected  with  Adenoma      .......  269 

Tubercular  Abscess  of  the  Ovary       ......  277 

Adenoma  of  the  Fallopian  Tube        .         .         .         .         .         .281 

Microscopical  Characters  of  a  Fallopian  Adenoma  .  .  .  282 
Adenoma  of  the  Fallopian  Tube  (Dr.  Walter's  case)  .  .  283 
Fallopian   Tube   strangulated   by   an    adhesion    between    the 

Ovary  and  Intestine  ........  285 

Gravid  Fallopian  Tube  at  the  sixth  week  .         .         .         .         •  313 

Gravid   Fallopian  Tube  at   the  tenth   week,  showing  complete 

occlusion  of  the  Ostium      .......  313 

Left    Fallopian    Tube    and    adjacent   portion   of   the    Uterus 

(Tube  occupied  by  Tubal  Mole)  .         .         .         .         '318 


xvi  Diseases  of  th/'I  Ovaries^  etc. 

I'AGE 

Apoplectic  Ovum,  or  Tubal  Mole 319 

Microscopical   appearances   of    Chorionic   Villi   in    transverse 

section 320 

Gravid  Fallopian  Tube  (after  tubal  abortion)    .         .         .         .  329 

Ovarian  Hydrocele  .         .         .         .         .         .         .         .         -331 

Transverse  section  of  the  Pelvis  of  a  Woman  with  an  Embryo 
and  Placenta  of  the  fourth  month  of  gestation  occupying 

the  right  Broad  Ligament 338 

Sagittal  section  of  a  Cadaver,  with  a  Broad   Ligament   Preg- 
nancy at  term 339 

Tubo-uterine  Pregnancy .  349 

Tubo-uterine  Pregnancy  ;  the  Gestation  Sac  ruptured  at  the 

month        . 351 

■Bicornuate  Uterus   [titertis  Bicornis  ttnicoUis)   three  days  after  ' 
delivery,    to  show  enlargement  of  both  cornua  when  one 

half  is  gravid 356 

Pregnancy  in  a  Rudimentary  Uterine  Cornu      ....  358 

Lithopaedion 373 

Mass  of  Foetal  bones,  from  a  case  of  extra- uterine  Pregnancy    .  377 
Another  view  of  the  same  group  of  bones  ....  379 

Uterus  of  an  Ewe     .........   382 

Incomplete  Delivery  in  a  Monkey,   due   to  abnormal   size  of 

the  Foetus         .........  384 

Mummified  Calf  retained  in  the  Uterus  eighteen  months  .         .   385 
Head  and  one  of  the  Feet  of  a  Lamb  retained  in  the  Uterus     .   386 
Intra-uterine  Maceration  of  a  retained  Lamb    ....   388 

Uterus  of  a  Jackal  which  ruptured  at  the  junction  of  vagina 

and  cervix         .........   393 

Gravid  Fallopian  Tube  which   ruptured  and   caused  death  in 

twelve  hours    .         .         .         .         .         .         .         .         .  404 

Gravid  Tube.    The  gestation  sac  ruptured  and  caused  death  in 

about  forty- eight  hours     .         .         .         .         .         .         .  407 

Gravid  Fallopian  Tube  which  has  ruptured      ....  409 

Head  of  a  Doe  {Capreohis  caprcca)  with  Antlers       .         .         .  478 


SURGICAL     DISEASES 

OF   THE 

OVARIES  AND  FALLOPIAN  TUBES, 

Including  Tubal  Pregnancy. 


!3art  X« 
DISEASES     OF     THE     OVARIES. 


CHAPTER    I. 

SEX  ;    THE  GENITAL  GLAND    OF   THE  FEMALE  ;    SECONDARY 
SEXUAL    CHARACTERS  ;    MENSTRUATION. 

Sex  is  a  term  used  to  express  the  characters  by  which 
an  animal  or  plant  is  male  or  female.  These  characters 
form  two  groups.  Primary  sexual  characters  are  those 
directly  associated  with  the  essential  function  of  repro- 
duction, and  comprise  in  the  human  female  the  ovaries, 
Fallopian  tubes,  and  uterus.  To  these  must  be  added 
the  mammary  glands.  The  dominant  sexual  organs  in 
the  female  are  the  genital  glands^  or  ovaries.  In  size  the 
ovaries  vary  much,  and  it  is  unusual  to  find  both  of 
equal  size.  In  outline  a  mature  ovary  is  oval,  but  com- 
pressed in  its  long  axis,  which  measures  from  3  to  5  cm. ; 
transversely  it  measures  from  2  to  3  cm.,  and  is  about 
12  mm.  in  thickness  (Fig.  i). 

The  smoothness  of  its  surface  is  interrupted  by  pro- 
minences caused  by  ripening  follicles,  and  by  scars  which  in- 
dicate the  spots  where  follicles  have  ruptured  ( Figs.  2  and  3). 

Towards  the  close  of  sexual  life  the  ovaries  become 


2  Diseases  of  the  Ovaries. 

smaller,  and  the  shrinking  of  the  stroma  causes  wrinkling 
of  the  capsule.  The  external  covering  of  the  ovary  is 
directly  continuous  with  the  posterior  layer  of  the  broad 
ligament.     Its  outer  covering  is  called  the  albuginea. 

On  microscopic  examination  the  ovary  will  be  found 
to  consist  of  two  distinct  parts.     That  portion  forming 


Fig.  I.— Ovary  of  a'Woman  23  years  old,  with  the  Fallopian  Tube  in 
position.     Natural  size. 

its  free  border  is  the  ooplioroii ;  it  is  the  egg-bearing 
segment,  and  is  full  of  follicles  in  various  stages  of 
development,  maturation,  and  decay.  The  ripe  follicles 
are  easily  recognised  by  their  size,  and  the  recently 
ruptured  follicles  usually  present  themselves  as  corpora 
lufea,  so  called  in  consequence  of  the  peculiar  yellow 
colour  of  the  tissue  of  which  they  are  mainly  composed. 
The    portion    in    relation    with    the    hilum    is    the 


Secondary  Sexual  Cj/aracteks.  3 

paroophoron  ;  it  never  contains  follicles,  and  is  usually 
composed  of  fibrous  tissue  traversed  by  numerous  blood- 
vessels. In  young  ovaries  the  paroophoron  may  present 
remnants  of  gland  tubules,  vestiges  of  the  mesonephros 
(Wolffian  body)  from  which  it  is  mainly  derived.  The 
excretory  tubules  and  ducts  of  that  interesting  structure 
are  invariably  attached  to  the  ovary  and  known  as  the 
parovarium.     The    ova  after  their   escape   from  the 


Fig.  2. — Ovary  from   a  Woman  40  years  of  age.     Natural  size. 


ovary  fall  into  the  peritoneal  cavity  in  order  to  enter  the 
Fallopian  tube  to  be  conducted  to  the  uterus. 

It  is  a  remarkable  fact  that  the  early  embryo  of  all 
mammals  possesses  in  a  potential  form  the  primary 
sexual  organs  of  both  sexes.  After  a  certain  period  one 
set  of  organs  predominates  and  determines  the  sex. 
Every  fully-formed  mature  female  possesses  vestiges  of- 
the  male  sexual  organ  except  the  genital  gland  \  and 
every  male  has  remnants  of  the  female  sexual  organs, 
save  the  ovary. 

Secondary    sexual    characters    are  those    fea- 
tures which  enable  us  to   distinguish  male  and  female, 
B  2 


Diseases  of  the  Oi'aries. 


irrespective  of  the  organs  of  reproduction  and  those  used 
for  the  nourishment  or  protection  of  the  young. 

The  characters  belonging  to  this  group,  so  far  as  the 
human  family  is  concerned,  are  exclusively  in  the  posses- 
sion of  the  male.  Man  is  distinguished  from  woman  not 
only  in  the  possession  of  a  beard  and  greater  muscular 
development  with  its  necessary  accompaniment,  greater 
physical  strength,  but  he  has  a  more  powerful  voice,  and 
the  skin  of  his  trunk  and  limbs  is  thick  and  more  abun- 
dantly supplied  with  coarse 
hair,  which  has  a  some- 
what different  disposition 
than  in  w^omen.  In  man 
the  front  of  the  chest  is 
usually  covered  with  hair. 
The  hair  on  the  pubes  in 
the  male  passes  upwards 
to  the  umbilicus,  whereas 
in  the  female  it  is  restricted 
to  the  pubes.  A  less  con- 
stant feature,  but  one 
which  seems  confined  to  men,  is  a  luxuriant  growth 
of  hair  on  the  prominence  of  the  pinna  know^n  as  the 
tragus. 

Secondary  sexual  characters  are  not  present  in  the 
young,  but  become  manifest  at  puberty,  by  which,  term 
we  signify  reproductive  maturity.  At  this  period  the 
generative  organs  increase  in  size,  and  in  the  male  be- 
come functionally  active.  In  the  female  puberty  is  more 
strikingly  declared  by  the  institution  of  iiieiiiiitriiatioii. 
It  is  a  remarkable  fact  that,  as  Darwin  observes, 
"  Throughout  the  animal  kingdom,  when  sexes  differ  in 
external  appearance,  it  is,  with  rare  exceptions,  the  male 
which  has  been  the  more  modified :  for,  generally,  the 
female  retains  a  closer  resemblance  to  the  young  of  her 


Fig.  3. — Section    of    Ovary    showing 
ripening  Follicles.     Natural  size. 


Mens  tr  ua  tion.  5 

own  species  than  to  other  adult  members  of  the  same 
group."  I'his  is  well  shown  in  the  human  family,  for  up  to 
the  period  of  puberty,  so  far  as  secondary  sexual  characters 
are  concerned,  the  boy  resembles  the  female  as  much  as  he 
does  the  male,  but  after  that  period  he  begins  to  assume 
secondary  sexual  characters  indicative  of  the  man. 

It  is  well  known  that  if  the  sexual  glands  be  destroyed, 
either  designedly  or  by  disease,  the  boy  will  retain 
feminine  peculiarities.  The  voice  will  remain  of  a 
childish  treble,  hair  is  scanty  over  the  pubes,  the  skin  is 
soft,  and  the  beard  fails  to  appear.  There  is  a  great 
tendency  to  an  abnormal  deposition  of  fat  in  the  sub- 
cutaneous tissues.  All  these  conditions  are  exhibited  in 
the  case  of  eunuchs. 

In  children  with  malformation  of  the  genital  organs 
the  secondary  sexual  characters  are  not  only  late  in 
appearing,  but  are  imperfectly  developed.  In  question- 
able cases  of  sex  the  only  absolute  test  is  the  genital 
gland.  The  presence  of  an  ovary  is  decisive  proof  of  a 
female,  and  the  testis  indicates  the  male.  The  other 
sexual  organs  are  quite  secondary,  for  a  uterus  has 
been  found  associated  with  testes.  The  nature  of  the 
genital  gland  cannot  be  determined  by  naked-eye  appear- 
ances, but  must  be  in  doubtful  cases  examined  micro- 
scopically. On  several  occasions  bodies  suspected  to  be 
ovaries  have  turned  out  to  be  testes  when  submitted  to 
this  test.  No  case  has  yet  been  recorded  in  the  human 
family  of  a  functional  ovary  co-existing  with  a  functional 
testis,  or  the  combined  condition,  so  common  in  frogs, 
known  as  an  ovo-testis. 

Menstruation  is  a  process  peculiar  to  the  female, 
and  as  interference  with  menstruation  is  a  very  im- 
portant feature  in  ovarian  and  tubal  disease,  it  is 
necessary  to  consider  the  chief  points  connected  with  this 
extraordinary  phenomenon,  and  its  aberrations,  early  in 


6  Diseases  of  the  Ovaries. 

this  volume.  In  the  British  Isles  the  average  age  at  which 
menstruation  begins  is  the  fourteenth  year,  and  it  con- 
tinues till  the  forty-fifth  year.  It  consists  in  the  escape 
from  the  vagina  of  a  bloody  fluid,  resembling  prune  juice 
in  colour,  acid  in  reaction,  and  non-coagulable.  Micro- 
scopically examined,  menstrual  fluid  consists  Of  blood 
corpuscles  and  epithelial  cells.  The  epithelium  is  fur- 
nished by  the  mucous  membrane  of  the  uterus  and 
vagina.  The  actual  source  of  the  blood  is  the  mucous 
membrane  of  the  uterine  cavity.  The  flux  lasts  on  an 
average  five  days,  and  the  quantity  is  about  six  ounces. 
The  normal  menstrual  rhythm  is  twenty-eight  days, 
counting  from  the  beginning  of  one  period  to  the 
beginning  of  another. 

Concerning  the  cause,  significance,  and  utility  of 
menstruation  we  know  nothing,  and  there  is  even  much 
diversity  of  opinion  regarding  the  changes  in  the  uterus 
at  the  menstrual  period. 

It  is  believed  by  many  that  menstruation  is  accom- 
panied by  gross  changes  in  the  uterine  mucous  mem- 
brane. Pouchet  *  maintained  that  an  exfoliation  of  the 
epithelium  of  the  uterus  occurred  monthly  in  women 
and  mammalia  generally,  and  that  there  was  also  de- 
struction and  expulsion  of  the  mucous  membrane. 

Dr.  John  Williams f  has  forcibly  urged,  a  similar 
opinion  in  regard  to  women.  His  observations  led  him 
to  believe  that  at  each  menstrual  period  the  epithelium 
and  subjacent  parts  of  the  mucous  membrane  lining  the 
uterine  cavity  are  shed,  the  denudation  commencing  at 
the  internal  os,  and  extending  to  the  fundus  ;  the  lost 
tissues  being  regenerated  in  the  inter-menstrual  period. 


*  Farre's   article    "Uterus:"     Todd's    Cyclopcvdia,   vol.  v.;     Sup- 
plement, p.  666. 

t  Obsf.  Joit7'nal,  vol.  ii.  ;   1875. 


Menstruajiox  in  Monkeys.  7 

From  this  extreme  view  many  observers  have  dis- 
sented. Some  beHeve  that  only  the  most  superficial 
parts  of  the  mucous  membrane  are  detached,  whilst 
others  state  that  it  remains  intact ;  not  even  the  ciliated 
epithelium  being  lost.  Opinions  were  so  contradictory  on 
this  subject  that  there  seemed  little  chance  of  reconciling 
them.  A  study  of  the  mucous  membrane  of  uteri  ob- 
tained from  young  women  dying  during  menstruation 
induced  me  to  believe  that  the  loss  of  tissue  described 
by  many  writers  is  the  result  of  post  mortem  change,  due 
to  the  almost  insuperable  difificulties  of  obtaining  the 
parts  before  they  lost  their  tissue-life.  It  occurred  to 
me,  therefore,  to  examine  the  conditions  of  the  mucous 
membrane  of  the  Fallopian  tubes  of  women  during 
menstruation,  and  also  to  investigate  the  uterine  and 
tubal  mucous  membrane  of  Macaque  monkeys  during 
that  period. 

As  far  as  my  observations  have  extended,  the  only 
mammals  which  menstruate  besides  women  are  Macaque 
monkeys  and  baboons.  In  Macaques,  menstruation  is 
accompanied  by  certain  unmistakable  objective  phenomena 
other  than  the  escape  of  blood  from  the  genital  passage, 
for  all  the  naked  or  pale-coloured  parts  of  the  body,  such 
as  the  face,  neck,  and  ischial  regions,  assume  a  lively 
pink  colour ;  in  some  cases  it  is  a  vivid  red.  The  amount 
of  sanguineous  discharge  from  the  uterus  is  very  slight, 
and  soon  ceases,  but  the  coincident  coloration  of  the 
parts  lasts  from  three  to  seven  days.  In  warm  weather, 
during  menstruation,  the  labia  are  much  swollen.  The 
baboons  present  similar  objective  signs  to  the  Macaques, 
but  in  an  exaggerated  degree,  so  that  a  menstruating 
baboon  is  anything  but  a  comely  individual.  After 
witnessing  these  outward  signs  of  menstruation  in  many 
Macaques  and  baboons,  and  ascertaining  beyond  all 
doubt  that  there  was   an  actual   flux   of  blood  at  these 


8  Diseases  of  the  Ovaries. 

periods,  some  of  them  were  killed  when  the  catamenia 
appeared  :  some  at  the  full  height,  and  others  at  its 
decline.  In  most  cases  the  uterus  was  removed  and 
placed  in  conservative  media  (Midler's  fluid  gave  best 
results)  the  instant  death  occurred.  This  enabled  me  to 
obtain  some  beautiful  and  reliable  specimens.  In  none 
of  them  could  any  trace  of  destructive  change  be  de- 
tected either  in  the  uterus  or  Fallopian  tubes — not  even 
shedding  of  the  epithelium. 

The  uterus  of  a  Macaque  monkey  is  very  instructive 
for  this  purpose.  In  shape,  and  even  in  the  structure  of 
the  mucous  membrane  and  disposition  of  glands,  it  is  so 
very  similar  to  that  of  our  own  species  that  it  may  be 
described  as  a  miniature  human  uterus.  The  glands  and 
their  ducts  are  lined  with  columnar  ciliated  epithelium. 

My  observations  threw  no  light  whatever  on  the 
source  or  cause  of  the  haemorrhage. 

The  uteri  of  baboons  gave  similar  results  when  the 
same  precautions  were  observed  in  obtaining  and  pre- 
serving the  specimens.  The  uterine  glands  in  the 
baboon  differ  in  shape  from  those  of  the  Macaque. 
Instead  of  long  tubular  glands,  they  are  crypts  in  the 
mucous  membrane,  recalling  in  a  striking  manner  the 
Lieberkiihnian  recesses  of  the  intestine.  The  uterine 
glands  of  the  baboon  often  present  shallow  diverticula 
at  their  bases  ;  the  glands  are  so  closely  packed  together 
that  the  mucous  membrane,  when  seen  in  section_,  has  a 
villous  appearance.  The  epithelium  is  columnar  and 
ciliated. 

The  Fallopian  tubes  of  the  Macaques  were  especially 
subjected  to  microscopic  examination,  and,  like  the  uterus, 
showed  no  evidence  of  epithelial  change  (Fig.  4). 

This  induced  me  to  examine  microscopically  Fal- 
lopian tubes  from  the  human  female  during  menstruation. 
This  seems  to  have  been  neglected  by  previous  writers 


Menstruation  I^  Monkeys.  9 

on  the  subject.  The  Fallopian  tubes  examined  were 
obtained  by  operation  performed  for  ovarian  tumours  or 
to  produce  an  artifici'al  menopause  in  women  suffering 
from  uterine  myomata.     The  tubes  specially  investigated 


-V 


r^-j 


-^ 


■%^'^    .ff<#f- 


-;i> 


"if 


'^itk 


X 


i 


-v^xt^ 


v4 


'^^'fi\^ 


Fig.  4.—  Microscopical  Appearances  of  a  transverse  Section  of  the  Fallopian  Tube 
of  a  Macaque  Monkey  {Macaciis  rhesus)  during  Menstruation. 


were  those  removed  during  menstruation,  and  immedi- 
ately after  their  abstraction  were  put  into  preservative 
media.  None  of  the  specimens  showed  any  change  in 
the  mucous  membrane  or  epithelium. 

My  observations  were  communicated  to  the  British 
Gynaecological  Society  in  1886.  The  inquiry  has  been 
continued  at   intervals  since    that   date   as  leisure  and 


lo  Diseases  of  the  Ovaries, 

opportunity  allowed,  and  the  conclusions  arrived  at  arc 
simple. 

1.  Macaque  monkeys  and  baboons  suffer  a  periodical 

loss  of  blood  from  the  uterus. 

2.  It  is  unaccompanied  by  any  destructive  change  of 

epithelium,  either  in  the  uterus  or  Fallopian 
tubes. 

3.  It  appears  to  recur  once  in  six  weeks  in  summer  ; 

it  is,  however,  difficult  to  decide  the  exact  length 
of  the  menstrual  rhythm. 

4.  In  the  human  female  the  mucous  membrane  of 

the  Fallopian  tube  undergoes  no  structural 
change  during  menstruation, 

5.  In  the  human  uterus    the   destructive    change  is 

limited  to  shedding  of  the  epithelium,  and  it  is 
doubtful  if  this  occurs  normally. 

We  must  now  consider  the  relation  of  ovulation 
to  menstruation,  and  the  phenomenon  known  as  oestrus, 
or  rut. 

Many — we  may  say  the  majority — think  that  menstru- 
ation and  rut  are  more  or  less  identical.  Farre  puts 
the  matter  very  clearly  and  concisely  in  the  following 
sentences  : — ■ 

"  In  the  mammalia  the  periods  of  emission  of  ova 
from  the  ovary  and  of  their  passage  down  the  Fallopian 
tube  are  undoubtedly  coincident  with  oestrus.  It  is 
only  on  these  occasions  that  the  female  manifests  an 
instinctive  desire  for  copulation.  She  is  then  said  to  be 
in  heat.  The  vulva  is  congested,  swollen,  and  bedewed 
with  an  increased  secretion,  which  is  generally  odorous, 
and  is  sometimes  tinged  with  blood.  This  condition  is 
of  brief  duration.  At  the  longest  it  continues  for  a  few 
days.  But  whatever  be  its  duration,  it  is  the  only  period 
during  which  the  female  can  be  impregnated." 

"In    the   human    subject   the    periodical   return    of 


CESTRUATION.  II 

congestion  of  the  reproductive  organs,  the  menstrual 
flow,  and  the  corresponding  emission  of  ova,  so  far  as 
this  point  has  yet  been  ascertained  by  post  morfejii 
examination,  accord  with  the  phenomena  displayed  by 
mammalia  during  oestrus.  It  is  also  believed  that  in 
some  instances  conception  has  taken  place  diiri?ig  men- 
struation :  a  circumstance  which  is  clearly  reconcilable 
with  the  anatomical  evidences  already  produced,  and  is 
so  far  in  accordance  with  what  normally  occurs  in  the 
mammalia  during  oestruation.  But  here  the  analogy 
ceases." 

Since  Farre  penned  those  sentences  our  knowledge 
of  the  natural  history  of  the  human  ovary  has  been 
rendered  more  certain  by  exact  observations  on  this 
gland,  which  have  been  possible  in  consequence  of  the 
advance  in  abdominal  surgery.  It  is  very  difficult  to  up- 
root a  tradition,  especially  one  so  ancient  as  the  belief  in 
the  intimate  association  of  ovulation  and  menstruation ; 
but  -  evidence  is  rapidly  accumulating  which  will  show 
that  the  two  processes  are  not  so  intimately  connected  as 
was  formerly  believed.  It  is  important  that  we  should 
consider  ovulation  in  the  light  of  these  observations,  as  it 
tends  to  widen  the  difference  between  menstruation  and 
rut,  which  Farre  believed  to  be  somewhat  analogous,  but 
not  identical. 

In  the  ovary  of  the  human  foetus,  ova  ripen,  form 
follicles,  and  undergo  suppression  during  the  last  month 
of  intra-uterine  life.  This  has  been  observed  by  De 
Sinety,  Waldeyer,  Begel,  and  others.  I  have  also  assured 
myself  of  these  facts,  and  have  also  detected  a  similar 
process  in  the  ovaries  of  foetal  mammals,  including  forms 
as  widely  separate  as  kangaroos  and  lemurs,  deer  and 
monkeys,  sloths  and  lions. 

The  life  of  the  human  ovary  may  be  divided  into  the 
following  periods  of  activity  and  repose.     The  first  period 


12  Diseases  of  the  Ovaries. 

extends  from  the  seventh  month  of  intra-uterine  Ufe  to 
the  end  of  the  first  year.  Ova  ripen  in  such  abundance 
that  in  some  cases  a  marked  diminution  in  the  number 
of  the  ova  is  appreciable  at  the  second  year  after  birth. 
To  this  succeeds  a  period  of  comparative  repose  termi- 
nating at  the  tenth  or  twelfth  year,  then  the  ripening  of 
ova  is  again  easily  detected,  and  goes  on  independently 
of  menstruation,  even  after  the  accession  of  the  cli- 
macteric. 

In  female  monkeys  and  women  ovulation  and  men- 
struation appear  to  be  independent  processes.  Matura- 
tion of  ova  from  the  period  of  puberty  until  senility  is 
going  on  constantly,  and  the  presence  of  a  ripe  ovum 
concurrently  with  menstruation  is  a  coincidence ;  in  a 
healthy  woman  a  ripe  follicle  may  generally  be  found 
in  the  ovary  between  the  tenth  and  fiftieth  year,  inde- 
pendently of  a  menstrual  period.  Thus  menstruation 
may  be  defined  as  a  periodical  monthly  discharge  of 
blood  from  the  uterus. 

The  oestrus,  rut,  or  heat  of  mammals  is  a  term  applied 
to  certain  objective  signs  that  the  female  will  receive  the 
male,  and  is  usually  associated  with  ovulation. 

Ovulation  signifies  the  escape  of  mature  ova  from  the 
ovary. 

Although  these  three  processes  may  occur  indepen- 
dently of  each  other,  still  we  cannot  but  doubt  that  they 
are  physiologically  associated  ;  and  it  is  a  fact  beyond  dis- 
pute that  if  the  ovaries  and  Fallopian  tubes  be  removed 
from  a  w^oman  who  has  menstruated  with  the  greatest 
regularity  for  years  and  is  still  in  the  bloom  of  sexual 
life,  we  may  predict  with  almost  absolute  certainty  that 
menstruation  will  cease. 

The  removal  of  the  ovaries  and  tubes,  with  the 
adjacent  portions  of  the  mesometrium,  has  now  been 
performed  in  women  for  diseases  of  the  ovaries  or  tubes 


Mens  tr  ua  tion.  i  3 

many  hundreds  of  times,  with  the  ahnost  invariable  result 
of  immediately  and  permanently  arresting  menstruation. 
In  many  cases,  as  we  shall  find  later,  these  parts  are 
removed  in  some  forms  of  uterine  tumour  for  the  purpose 
of  producing  an  artificial  menopause.  Lawson  Tait  *  is 
disposed  to  believe  that  the  tubes  are  not  without  some 
influence  on  menstruation.  Instances  in  which  the 
ovaries  have  been  removed  and  the  tubes  allowed  to 
remain,  or  cases  in  which  the  tubes  were  removed  and 
the  ovaries  left  behind,  are  very  few ;  but  sufficient  cases 
have  been  recorded  to  render  it  absolutely  certain  that 
the  dominant  organs  of  the  menstrual  function  are  the 
ovaries.  It  is  necessary  to  use  the  plural,  because  extir- 
pation of  one  ovary  exercises  no  influence  on  men- 
struation. In  a  few  cases  it  is  believed  that  menstruation 
has  continued  or  reappeared  even  after  complete  removal 
of  both  ovaries  and  tubes.  This  subject  is  of  so  much 
interest  and  importance  that  a  full  discussion  of  the 
evidence  relating  to  it  will  be  deferred  to  chapter  xlii. 
This  much,  however,  is  certain  :  that  the  subjoined  opinion 
expressed  by  Farre  in  1859  relative  to  the  influence  of 
the  ovaries  on  menstruation — "  Their  artificial  removal 
is  followed  by  a  permanent  cessation  of  the  catamenial 
flow,  although  the  uterus  may  be  left  uninjured  ;  while 
the  congenital  absence  of  both  ovaries  is  always  accom- 
panied by  an  enduring  amenorrhoea  '' — ^^holds  good  in  the 
present  day. 

*  Diseases  of  the  Ovaries,  p.  25  ;  1883. 


14 


CHAPTER    11. 

CYSTIC     CORPORA     LUTEA  ;      APOPLEXY     OF     THE     OVARY  ; 
OVARIAN    CONCRETIONS. 

The  corpus  liiteiini. — When  the  contents  of  a 
mature  folhcle  are  discharged,  the  cavity  of  the  folhcle,  at 
first  filled  with  blood,  becomes  gradually  occupied  by 
reddish-yellow  tissue,  which  assumes  an  irregular  shape 
and  forms  a  body  termed  the  corpiis  luteiim.  Should 
the  ovum  become  fecundated,  the  corpus  luteum  increases 
in  size,  and  persists  as  a  conspicuous  object  in  the  ovary 
throughout  the  whole  period  of  gestation. 

In  an  unimpregnated  female  the  corpus  luteum 
begins  to  degenerate  within  ten  or  fourteen  days  after  the 
escape  of  the  ovum,  and  finally  disappears. 

No  satisfactory  explanation  is  forthcoming  regarding 
the  cause  of  a  corpus  luteum.  Dr.  Ritchie  (the  elder) 
pointed  out  that  the  mere  rupture  of  an  ovarian  follicle 
is  insufficient  to  produce  a  corpus  luteum,  and  he 
attempted  to  show  that  its  formation  depended  on 
menstruation.  This  is  not  the  case,  as  corpora  lutea 
occur  independently  of  this  process  in  the  ovaries 
of  infants  and  non-pubic  girls. 

It  should  be  borne  in  mind  that  a  corpus  luteum  is 
not  always  present  in  pregnancy.  To  put  it  in  the  words 
of  Parry,*  "  Its  presence  is  the  rule,  its  absence  is  the 
exception,  especially  in  the  early  months  of  gestation." 

Dr.  Popowf  has  recorded  two  cases  in  which  he  has 

*  Ectopic  Pregnancy. 

t   Trans.  Obstet.  Soc,  London,  vol.  xxiv.  p.  loo. 


Cvsric  Corpora  Lute  a.  15 

found  true  corpora  lutea  unassociated  with  pregnancy. 
In  the  ovary  of  a  prostitute,  twenty-one  years  of  age,  who 
committed  suicide  by  prussic  acid,  he  found  "a  fully  ripe 
corpus  luteum."  The  woman  was  neither  menstruating 
nor  pregnant. 

The  second  case  was  a  woman  forty-one  years  of  age, 
who  had  not  borne  children  for  twelve  years.  She  died 
from  gangrene  of  a  fibro-myoma  of  the  cervical  canal. 
The  right  ovary  contained  a  true  corpus  luteum. 

Matthews  Duncan,  in  his  remarks  on  this  paper,  said  : 
'•'  He  has  seen  a  good  corpus  luteum,  as  far  as  naked-eye 
appearances  went,  in  an  aged  woman,  who  was  believed 
to  be  salacious.  He  had  more  than  once  dissected  cases 
of  pregnancy,  with  complete  absence  of  the  corpus 
luteum." 

The  two  largest  corpora  lutea  that  have  come  under 
my  observation  were  in  ovaries  removed  for  the  purpose 
of  anticipating  the  menopause  in  cases  of  rapidly-growing 
uterine  myomata.  The  patients'  ages  were  forty  and 
forty-five  ^^ears  respectively.  One  had  never  been  preg- 
nant, and  the  other  had  had  no  child  for  ten  years. 

Cystic  corpora  lutea. — Rokitansky  long  ago 
observed  that  these  bodies  are  occasionally  occupied  by 
a  central  cavity ;  and  he  held  the  opinion  that  they  might 
enlarge,  and  form  tumours  of  sufficient  size  to  become 
clinically  important. 

Most  observers  who  have  worked  at  ovarian  pa- 
thology have  detected  examples  of  this  form  of  cyst ; 
the  peculiar  yellow  colour  of  their  walls  enables  them  to 
be  readily  recognised. 

I  have  devoted  much  time  to  examining  ovaries  in 
the  human  subject,  for  the  express  purpose  of  ascertaining 
if  cysts  in  corpora  lutea  ever  give  rise  to  tumours  which 
could  be  perceived  during  life ;  and  though  I  have  on 
several   occasions  met   with    such    cysts,  which    formed 


1 6  jD  IS  EASES    OF    THE    O  VARIES. 

prominences  on  the  surface  of  an  ovary  as  large  as  ripe 
cherries,  they  never  caused  any  inconvenience  to  the 
individual  who  possessed  them. 

In  domestic  mammals — the  cow,  ewe,  mare,  and  sow 
— they  are  extremely  common  ;  in  the  cow  they  may 
attain  the  size  of  a  Tangerine  orange. 

In  all  cases  the  walls  of  such  cysts  are  thick,  and  of 
a  bright  yellow  colour,  when  fresh ;  the  cavity  is  lined  by 
a  thin  delicate  membrane,  and  filled  with  albuminous 
fluid. 

Corpora  fibrosa. — Patenko*  has  described,  under 
this  term,  the  tough,  semi-opaque  fibrous  bodies  occa- 
sionally found  in  ovaries.  They  are  probably  due  to 
fibrous  changes  in  the  tissue  of  the  corpus  luteum.  Some 
corpora  fibrosa  contain  a  small  central  cavity,  others  a 
laminated  body,  possibly  due  to  colloid  change  of  the 
central  parts  of  the  corpus  luteum. 

Patenko  states  that  corpora  fibrosa  may  attain  the 
size  of  a  hen's  egg.  Sometimes  these  fibrous  bodies  are 
pedunculated. 

Apoplexy  of  the  ovary. — The  rupture  of  a  mature 
ovarian  follicle  is  always  accompanied  by  a  trifling 
amount  of  bleeding.  When  the  follicle  is  unusually  large, 
the  blood-clot  occupying  it  may  be  as  big  as  a  ripe 
gooseberry.  Hcemorrhage,  to  this  extent,  is  often 
associated  with  severe  ovarian  congestion,  such  as  ac- 
companies tubal  pregnancy,  miscarriage,  or  uterine 
tumour. 

Mild    haemorrhage    of    this    character    is,    by   some 
authors,  called  ovarian  apoplexy,  but  it  would  be  prefer- 
able to  describe  such  a  condition  2.^  follicular  hcBmorrhage, 
n   order  to  avoid  confounding  it  with  the  much  more 

*  Virchow's   Archiv,    vol.    xxxiv.    p.    193:     "  Ueber  die  Entwick-. 
lung  der  Corpora  fibrosa  in  Ovarien." 


Apoplexy  of  the  Oi'ary.  17 

serious  form  of  ovarian  hremorrhage  now  to  be  con- 
sidered. 

Winckel  states  that  he  has  three  times  seen  foUicular 
haemorrhages  in  women  who  have  died  after  burns  from 
petroleum.  One  of  the  patients  was  a  servant  girl, 
seventeen  years  of  age.  The  ovary  was  3-5  cm.  long, 
2  cm.  broad,  and  i*8  cm.  thick,  and  contained  fifteen 
follicles  filled  with  blood,  varying  in  size  from  the  head 
of  a  pin  to  that  of  a  pea.  He  has  also  met  with  it  twice 
after  phosphorus  poisoning,  and  three  times  after 
typhoid  fever. 

Follicular  hcxmorrhages  are  not  infrequent  in  the 
course  of  acute  fevers. 

Occasionally  blood  is  extravasated  so  freely  into  a 
follicle  that  it  bursts  the  walls  and  invades  the  stroma, 
converting  the  organ  into  a  cyst  the  walls  of  which  are 
formed  of  expanded  ovarian  tissue,  and  the  cavity  filled 
with  blood. 

For  such  conditions  the  term  ovarian  apoplexy  should 
be  reserved,  and  which,  with  Doran,*  may  be  defined  as 
hcdmorrhage  into  the  ovarian  stroma  through  rupture  of  a 
follicle  (Fig.  5). 

The  effects  depend  upon  the  amount  of  haemorrhage. 
The  ovary  may  become  distended  until  it  is  as  large  as  a 
billiard-ball;  such  cases  are  very  rare.  Dr.  Handfield 
Jones t  removed  an  ovary  the  size  of  an  orange  from 
a  woman  who  suffered  from  profuse  and  exhausting 
menorrhagia.  The  haemorrhage,  which  had  started  a  year 
previously,  after  a  serious  railway  injury,  had  reduced 
the  patient  to  a  condition  of  profound  anaemia  and 
debility.  The  loculi  of  the  diseased  ovary  were  filled 
with  liquid   blood  .in  varying  stages   of  decomposition. 

*   Trans,    Obstet.  Soc,  London,  vol.  xxxii.  p.  119.     This  valuable 
paper  is  founded  on  a  case  of  great  clinical  interest, 
t  Ibid.,  vol.  xxxiii.  p.  27. 


1 8  Diseases  of  the  Ovaries. 

After  the   operation   the   patient   had  rapidly  improved, 
and  no  further  haemorrhage  had  been  reported.     More 


OVARY 


Fig.  5. — Apoplexy  of  the  Ovary.    (Modified  from  Doran.)    {Trans.  Obstet.  Soc.) 

P,  A  fimbriated  Kobelt's  tube ;  .\,  crumpled  remains  of  the  uall  of  the  follicle  whence  the 
hemorrhage  proceeded, 

rarely  the  ovary  may  rupture,  and  the  blood,  escaping 
into  the  recto-vaginal  pouch,  forms  what  is  usually  called 
a  pelvic  h^ematocele.     Some  ^Yriters  even  go  so  far  as  to 


Oi'ARiAN  Concretions.  19 

believe  that  when  apoplexy  of  the  ovary  causes  rupture 
of  the  organ  the  haemorrhage  may  be  fatal.  A  critical 
examination  of  the  published  cases  leads  me  to  suspect 
that  in  many  reported  examples  of  this  accident  the  fatal 
bleeding  was  caused  by  rupture  of  a  gravid  tube  or  tubal 
abortion. 

I  once  reported  a  case  of  pelvic  h?ematocele  as  being 
due  to  bursting  of  an  enlarged  ovarian  follicle.  Fortu- 
nately, the  parts  were  preserved.  Several  years  later  I 
re-examined  the  specimen,  and  found  the  haemorrhage 
was  caused  by  rupture  of  a  gravid  tube ;  the  ovum  was 
detected  among  the  blood-clot. 

Enlarged  ovarian  follicles  distended  with  blood  are 
so  frequently  associated  with  tubal  gestation  that  recorded 
cases  of  rupture  of  the  ovary  leading  to  severe  or  fatal 
hsemorrhage  must  be  accepted  with  the  utmost  caution. 
At  present  I  cannot  refer  to  a  reliable  instance  in  which 
ovarian  apoplexy  has  caused  death,  or  even  imperilled 
life.  Blood  extravasated  into  the  ovarian  stroma  under- 
goes the  same  change  as  when  it  escapes  into  other  solid 
organs  :  that  is,  the  fluid  parts  are  absorbed  and- the  clot 
gradually  becomes  decolorised^  until  nothing  but  a 
yellowish  mass  of  fibrin  remains.  Occasionally  it  will  be 
of  a  dirty  brown  colour,  resembling  that  found  in  an  old 
haematocele  of  the  tunica  vaginalis  testis. 

Ovarian  concretions. — The  only  instance  of  con- 
cretions occurring  in  the  ovary  is  recorded  by  Dr.  H. 
W.  G.  ^Mackenzie.*  The  patient  was  forty-one  years  of 
age,  and  had  suffered  for  two  years  from  menorrhagia , 
she  had  a  large  myoma  of  the  uterus.  The  ovaries  were 
enlarged,  and  contained  a  number  of  black,  hard,  flat 
bodies.  The  cavities  containing  them  were  smooth- 
walled.     The  concretions  were  of  various  sizes,  from  a 

*    Trans,  Path.  Soc,  London,  vol.  xl.  p.  198, 
C    2 


20 


Diseases  of  the  Ovaries 


coriander-seed  to  a  small  bean,  and  of  irregular  shape, 
but  their  surfaces  were  smooth  and  flattened  where  they 
had  come  in  contact  with  one  another.  They  were  firm 
and  hard,  but  light,  and  could  be  cut  with  a  knife  like 
very  hard  wax. 


TUBE 


CONCRETIONS 
FROM 

CAVITY. 


Fig.  6. — Ovary  with  Cysts  containing  Concretions      (Museum,  St.  Thomas's 

Hospital.) 


Under  the  microscope,  sections  prepared  from  the 
concretions  exhibited  no  structure,  but  there  were  indi- 
cations that  the  mass  consisted  of  spheroidal  bodies. 

Dr.  Copeman  attempted  to  determine  their  chemical 
constitution.  They  were  insoluble  in  acid  and  alkaline 
solutions,  and  in  ether  and  chloroform.  Prolonged 
digestion  with  artificial  gastric  juice  in  an  incubator  at 


Ovarian  Concretions.  21 

the  body  temperature  dissolved  them.  The  coloured 
solution  thus  obtained  gave  the  spectrum  of  acid 
hcematin  and  the  guaiacum  reaction  for  blood. 

The  concretions  probably  consisted  of  coagulated 
proteids  derived  from  blood-clot,  akin  to  lardacein, 
and  of  the  same  family  as  the  concretions  of  the 
prostate  and  the  amyloid  bodies  sometimes  found  in  old 
hcemorrhages. 

It  is  probable  that  the  cavities  which  contained  the 
concretions  were  ovarian  follicles,  and  that  blood  had 
been  effused  into  them  and  undergone  a  rare  colloid 
change. 

It  is  not  unusual  to  find  hard  clots  of  blood  in  ovarian 
follicles,  but  concretions  of  the  density  exhibited  in  this 
specimen  are  excessively  rare. 


CHAPTER   III. 

MALFORMATIONS;    MISPLACEMENT,    AND    ATROPHY    OF 
THE   OVARIES. 

The  ovaries,  like  other  organs  of  the  body,  are  h'able  to 
malformations  and  misplacements,  some  of  which  possess 
a  jDractical  interest. 

Coiig-eiiitnl  absence  of  both  ovaries  is  very  rare, 
and  is  always  associated  with  defective  development  of  the 
uterus.  Absence  of  one  ovary  has  been  several  times 
recorded,  with  deficiency  of  the  corresponding  half  of 
the  uterus  and  the  Fallopian  tube.  In  a  fair  proportion 
of  cases  there  is  absence  of  the  corresponding  kidney. 

A  tliird  or  accessory  ovary  has  been  mentioned 
by  a  few  writers.  Several  conditions  have  been  described 
as  third  ovaries.  The  most  frequent  is  when  an  ovary  is 
traversed  by  a  deep  fissure,  so  as  to  almost  isolate  a  portion 
of  the  gland.  Under  such  conditions  the  ovary  seems 
to  consist  of  two  parts,  united  by  a  narrow  isthmus.  It 
is  stated  that  the  ovary  may  be  so  deeply  fissured  that  it 
appears  as  if  composed  of  lobules.  Olshausen*  has 
collected  many  reported  cases  of  supernumerary  ovaries, 
and  refers  to  those  described  by  Beigel  and  Winckel.  I 
have  examined  the  drawings  in  Winckel's  work,  and  find 
that  he  gives  figures  of  ovaries  with  small  pedunculated 
bodies  attached  to  them  ;  but  these  are  not  in  any  sense 
supernumerary  ovaries.  Indeed,  the  statement  that 
Winckel  found  accessory  ovaries  eighteen  times  in  500 
bodies,  and  that  Beigel  found  them  eight  times  in  350  female 

*  Kraiikhciicn  der  Ovarie/i,  p.  15  ;   i386. 


Accessor]'  OrARiES.  23 

bodies,  is  sufficient  to  indicate  that  these  writers  must 
have  regarded  any  pedunculated  ])ody  near  the  ovary  as 
an  additional  ovary.  The  descriptions  of  some  of  the 
cases  render  it  exceedingly  probable  that  some  of  them 
were  the  pedunculated  bodies  so  frequently  found  near, 
and  in  relation  with,  the  parovarium.  A  few  were  pro- 
bably corpora  fibrosa.  So  far  as  the  evidence  at  present 
stands,  an  accessory  ovary  quite  separate  from  the  main 
gland,  so  as  to  form  a  distinct  organ,  has  yet  to  be 
described  by  a  competent  observer. 

Doran,"^  in  an  interesting  specimen  exhibited  at  the 
Pathological  Society,  showed  that  small  fibro-myomata 
may  arise  in  the  ovarian  ligament.  The  specimen  con- 
sisted of  the  left  ovary  with  its  ligament.  In  the  midst 
of  the  substance  of  the  ovarian  ligament  there  was  a 
small  spherical  tumour  about  12  mm.  in  diameter.  The 
tumour  was  composed  of  plain  muscle  fibres,  mingled 
with  white  fibrous  tissue.  When  the  parts  first  came  to 
light  during  the  operation,  it  appeared  to  be  a  super- 
numerary ovary,  but  microscopically  it  was  found  to  be  a 
fibro-myoma.  In  concluding  his  account  of  the  case 
Doran  writes  : — "  My  experience  in  this  case  leads  me  to 
believe  that  others  may  have  mistaken  a  fibro-myoma  of 
the  ovarian  ligament  for  a  supernumerary  ovary."  It  is 
a  very  remarkable  circumstance  that  the  opposite  ovary 
of  this  patient  presented  a  small  lobe,  such  as  is  termed 
a  supernumerary  ovary. 

Coiig-enital  inisplacements  of  the  ovaries  are 
very  rare.  In  the  early  embryo  they  are  situated,  like  the 
testicles,  in  close  relation  with  the  kidneys.  In  the  majority 
of  vertebrates  they  maintain  this  position  throughout  life. 
In  a  few  of  the  higher  mammals,  including  the  liuman 
female,  they  migrate  into  the  pelvis,  and  at  birth  they  lie 

*   Trans.  Path.  Soc,  London,  vol.  xxxviii.  p.  245. 


24  Diseases  of  the  Ovaries. 

on  the  psoas  magnus  muscle.  Soon  after  birth  the  ovaries 
occupy  a  position  in  the  true  pelvis,  near  its  brim,  until 
disturbed  by  the  first  pregnancy,  or  by  disease. 

In  very  rare  instances  an  ovary  may  be  retained  in 
relation  with  the  kidney.  An  example  of  this  came 
under  my  observation  in  a  foetus.  The  genital  organs 
were  well  developed,  but  the  right  ovary  was  adherent  to 
the  lower  border  of  the  corresponding  kidney  ;  the  csecum 
remained  in  the  right  hypochondrium,  adherent  to  the 
under  surface  of  the  liver. 

.  It  is  well  known  that  in  a  certain  proportion  of  cases 
of  non-descent  of  the  right  testis,  the  Ccecum  also  fails  to 
descend  into  its  natural  position  in  the  right  iliac  fossa. 
It  is  of  some  interest  to  find  retention  ot  the  right  ovary 
in  the  loin  associated  with  the  same  disposition  of  the 
caecum. 

This  is  the  only  example  of  non-descent  of  the  ovary 
which  has  come  under  my  observation  :  the  foetus  was 
born  at  full  time,  but  had  spina  bifida. 

Hernia,  of  tlie  ovary. — Many  cases  have  been 
recorded  in  which  a  body  supposed  to  be  an  ovary  has 
been  found  in  the  inguinal  canal.  It  is  curious,  not- 
withstanding the  fact  that  inguinal  hernia  is  extremely 
common  in  infants,  no  authentic  case  can  be  cited  iri 
which  an  ovary  has  been  found  in  a  hernial  sac  at  birth. 
Cases  reported  as  congenital  hernia  of  the  ovary  may  be 
ound,  the  nature  of  the  gland  being  determined  by  the 
naked  eye ;  there  is  no  example  on  record  in  which  the 
structure  of  such  a  body  was  examined  microscopically, 
and  found  to  be  an  ovary. 

That  this  precaution  is  absolutely  necessary  to 
establish  the  fact  is  shown  by  cases  in  which  herniated 
bodies,  supposed  to  be  ovaries,  were  found  on  micro- 
scopical examination  to  be  testes. 

One  of  the  most  remarkable  examples  was  recorded 


Hernia  of  the  Ovary.  25 

by  Dr.  Chambers.*  An  individual,  supposed  to  be  a 
woman,  aged  twenty-four  years,  had  observed  swelHngs 
in  the  groin  as  long  as  she  could  remember.  She  had 
never  menstruated  ;  her  breasts  were  well  developed,  but 
nippleless.  The  mons  veneris  was  destitute  of  hair,  the 
clitoris  and  labia  were  small,  and  the  vagina  ended  in  a 
cul-desac  an  inch  deep.  As  the  inguinal  swellings  caused 
the  patient  much  inconvenience  and  pain,  they  were 
removed.  They  were  shown  to  the  Obstetrical  Society, 
London,  as  ovaries.  They  were  subsequently  examined 
by  Drs.  J,  Williams  and  Galabin,  who  reported  that  the 
supposed  ovaries  exhibited  the  microscopical  characters 
of  testicles. 

It  is  also  important  to  bear  in  mind  that  when  organs 
supposed  to  be  ovaries  occupy  the  inguinal  canal,  and 
subsequent  dissection  of  the  individual  discloses  the 
existence  of  a  uterus,  it  is  no  reason  for  assuming  that 
the  genital  glands  were  ovaries. 

Whilst  dissecting  the  body  of  a  male  fcetus,  born  at 
the  eighth  month,  I  found  a  uterus  of  the  normal  size 
and  shape  behind  the  bladder,  and  communicating  by 
means  of  a  small  vagina  with  the  urethra  in  the  situation 
of  the  sinus  pocularis.  The  Fallopian  tubes  passed 
from  the  uterus  as  mere  threads  until  they  approached 
the  inguinal  canals,  then  each  expanded  to  form  a  fringed 
ampulla  in  relation  with  an  oval  body  of  the  size  of  a 
foetal  testicle  lying  just  below  the  internal  ring.  The 
microscope  showed  each  of  these  bodies  to  be  testicles. 
Franck  has  recorded  a  similar  persistence  of  the 
peritoneal  extremity  of  the  Fallopian  tube  in  relation 
with  normally  formed  testicles  in  a  foal. 

Stonhamf    exhibited    to    the    Pathological    Society, 


*    Trans.  Obsfef.  Soc,  Londov,  vol.  xxi.  p.  256. 
f    Trans.  Path.  Soc,  London,  vol.  xxxix.  p.  219. 


26 


Diseases  of  the  Ovaries. 


London,  the  genital  organs  of  a  child  in  which  a  uterus 
and  Fallopian  tubes  were  associated  with  testes. 

The  child  when  born  had  a  right  congenital  inguinal 


Fig.  7. — Genital    Organs  of  a  Pseudo-hermaphrodite.     (After  Stonham.) 
^'as  deferens  ;  t,  testes  ;  F,  Fallopian  tube  ;  b,  bulb  ;  v  vessels ;  r,  I,  round  ligament. 

hernia.  When  nine  months  old  an  attempt  was  made 
by  Mr.  Horsley  to  cure  the  hernia  by  operation.  When 
the  sac  was  opened,  an  organ  supposed  to  be  the  uterus 
with  Fallopian  tubes,  and  bodies  regarded  as  ovaries, 
were  found.  The  child  died  from  the  operation,  and 
Stonham  made   a   careful  dissection  of   the  parts,  and 


Hernia  of  the  Ovary.  27 

illustrated  his  paper  by  a  drawing,  reproduced  in  Fig.  7. 
The  bodies  which  occupied  the  inguinal  canals  were 
examined  microscopically,  and  found  to  be  testes.  If 
it  were  necessary,  several  similar  cases  could  be 
quoted. 

Mr.  Langton*  has  published  a  paper  of  much  clinical 
interest  on  "  Hernia  of  the  Ovary,"  founded  on  personal 
observation  at  the  City  of  London  Truss  Society. 

In  eight  years  he  saw  589  cases  of  inguinal  hernia  in 
female  children,  which  he  classes  as  cofigefiital,  because 
they  were  "^  for  the  first  time  discovered  either  at  birth 
or  within  the  first  year."  This  is,  of  course,  far  too 
wide  an  extension  of  the  true  meaning  of  the  word 
congenital.  Among  these  589  cases  there  were  forty- 
three  instances  in  which  movable  bodies  could  be  dis- 
tinguished in  the  canal.  These  movable  bodies  were 
oval,  hard,  somewhat  flattened,  w^ith  their  long  axes  in 
the  direction  of  Poupart's  ligament,  and  of  about  the 
size  of  a  testis  of  a  boy  of  corresponding  age.  Of  the 
forty-three  cases,  twenty-nine  were  reducible  and  fourteen 
were  irreducible;  in -seven  cases  a  movable  body  was 
present  on  each  side.  In  only  one  instance  was  the 
diagnosis  verified  by  dissection  :  "  In  this  child  the  pro- 
trusion was  ascertained  to  be  the  ovary  of  the  right  side, 
together  with  its  own  Fallopian  tube."  There  is  no 
evidence  that  the  ovarian  nature  of  this  gland  was 
demonstrated  microscopically. 

It  is  also  important  to  remember  that  in  none  of  these 
cases  was  there  malformation  of  the  external  genital 
organs. 

Interesting  as  these  facts  are  in  certain  directions, 
they  cannot  be  accepted  unreservedly  as  cases  of  ovarian 
hernia,  for  the  following  reasons  : — 

*  St.  Bartholomew'' s  Hospital  Reports,  vol.  xviii.  p.  199. 


28  Diseases  of  the  Ovaries. 

i.  In  all  cases  of  supposed  congenital  hernia  of  the 
ovary  the  nature  of  the  gland  must  be  substan- 
tiated by  microscopical  examination, 
ii.  The  association  of  a  Fallopian  tube,  or  the  sup- 
posed  or  real    existence   of  the  uterus,  is  no 
proof  that  the  movable  body  is  an  ovary, 
iii.  The  ovary  of  a  child  at  birth  is  not  rounded  like 
a  testis,  but  is  a  narrow  elongated  body,  not 
nearly  so  large  as  a  testis  of  corresponding  age. 
{See  Fig.  8.) 
iv.  Some  of  the  oval  movable  bodies  were  probably 

small  hydroceles. 
Thus  the  inferences  in  Mr.  Langton's  useful  paper 
are  not  sustained  by  facts,  and  there  is  every  need  to 
observe  his  cautious  expression  : — "  A  precise  diagnosis 
of  these  bodies  is  necessarily  somewhat  fallible,  and  can 
only  be  conclusively  set  at  rest  by  subsequent  dissection 
and  actual  microscopic  examination." 

I  do  not  deny  that  an  ovary  may  occupy  the  inguinal 
canal  at  birth,  but  no  such  case  has,  so  far  as  I  know, 
been  recorded  in  which  the  ovarian  nature  of  the  her- 
niated body  has  been   proved   by  microscopical  exami 
nation,  conducted  by  a  competent  observer. 

Bilton  Pollard"^  has  recorded  a  case  in  which  he 
excised  an  acutely  strangulated  ovary  and  a  portion  of 
the  Fallopian  tube  from  a  child  three  months  old. 

Acquired  lieriiia^  of  tlie  ovary. — The  ovary 
occasionally  occupies  the  sac  of  an  inguinal  hernia,  either 
alone  or  in  company  with  a  knuckle  of  gut  or  a  piece  of 
omentum. 

In  i88t,  whilst  I  was  dresser  to  Mr.  J.  W.  Hulke, 
a  woman,  aged  twenty  years,  came  under  observation 
with  a  troublesome  swelling  in  the  right  groin,  which  had 

*  Lancet,  1889,  vol.  ii.  p.  165. 


Acquired  Hernia  of  the  Ovary.  29 

existed  for  six  weeks.  Mr.  Hulke  explored  the  swelling, 
and  found  it  to  be  an  ovary,  with  the  adjacent  parts  of 
the  Fallopian  tube  attached  to  what  appeared  to  be  a 
bicornuate  uterus.  There  was  atresia  of  the  vagina.  On 
examining  the  gland  I  found  it  contained  two  corpora 
lutea  and  several  follicles,  and  exhibited  the  microscopical 
characters  of  an  ovary  The  left  ovary  was  removed  by 
Dr.  Heywood  Smith*  four  years  later. 

Dr.  Robert  Earnest  mentions  an  instance  of  acquired 
hernia  of  the  ovary  in  a  woman  forty-one  years  of  age. 
Its  ovarian  character  was  substantiated  microscopically 
by  Dr.  Goodhart. 

It  has  been  stated  that  in  acquired  hernia  of  the 
ovary  the  Fallopian  tube  does  not  usually  accompany  it ; 
(Englisch) ;  evidence  in  support  of  this  statement  is  very 
scanty. 

Concerning  acquired  hernia  of  the  ovary^  Mr.  Langton 
states  that  "  out  of  3,495  cases  of  inguinal  occurring  in 
females  of  all  ages  over  the  first  year  of  life,  there  were 
observed  only  24  examples,  or  i  in  145,  as  against  i  in  14 
congenital  cases." 

In  a  case  mentioned  by  Langton  in  the  paper  to 
which  reference  has  been  made,  "the  patient  was  a 
remarkably  well-developed  girl  of  seventeen  years  ;  in- 
guinal swellings,  regarded  as  herniated  ovaries,  had  been 
noticed  since  the  age  of  three  years.  She  continued 
under  observation  for  three  years,  but  had  not  men- 
struated."    This  is  significant. 

Cases  described  as  hernia  of  the  ovary  in  adults, 
based  on  clinical  evidence,  are  valueless.  When  re- 
moved, either  ante  mortem  or  post  7Jiortem,  their  ovarian 
nature  should  be  confirmed  with  the  microscope.     No 

*  Journal  of  the  Brit.  Gyn.  Soc,  vol.  i.  p.  321. 
t  Amer.  Journal  of  Obstet.,  vol.  xv.  p.  11. 


so  Diseases  of  the  Ovaries. 

more  striking  instance  of  the  necessity  of  this  could  be 
adduced  than  the  celebrated  case  recorded  by  Chambers. 

Prolapse  of  the  ©vary. — In  describing  the  situa- 
tion of  the  normal  ovaries,  it  was  pointed  out  that  in  the 
adult  female  they  are  situated  in  the  true  pelvis,  near  its 
brim,  until  disturbed  by  the  first  pregnancy  or  by  disease. 
From  this  position  they  may  be  displaced  by  three  sets 
of  causes,  each  of  which  will  be  briefly  considered. 

i.  Prcgnd7icy. — The  alterations  in  the  size  of  the 
uterus  during  pregnancy,  and  the  stretchmg  to  which  the 
broad  ligaments,  Fallopian  tubes,  and  ovarian  ligaments 
are  subjected,  causes  them,  especially  if  the  pregnancy  is 
frequently  repeated,  to  become  very  lax.  Under  these 
conditions,  one  or  other  ovary,  instead  of  retaining  its 
usual  position  at  the  brim  of  the  true  pelvis,  may  drop 
upon  or  near  the  floor  of  the  recto-vaginal  pouch. 
When  the  left  ovary  is  thus  displaced  it  lies  between 
the  upper  part  of  the  vagina  and  the  rectum. 

An  ovary  thus  displaced  is  said  to  be  prolapsed,  and 
not  infrequently  it  is  a  source  of  much  pain  and  distress, 
for  it  becomes  pressed  upon  during  defjecation,  and 
patients  complain  of  the  severe  pain  they  then  experience. 
Intense  pain  during  sexual  congress  (dyspareunia),  is 
another  symptom,  and  many  patients  with  displaced 
ovaries  will  state  that  the  approach  of  the  husband  is 
to  them  a  source  of  constant  dread.  On  examining  such 
patients  a  small  rounded  body  will  be  felt  behind  the 
uterus  ;  usually  it  is  movable,  and  feels  somewhat  like  a 
marble  lying  behind  that  organ.  Each  time  the  finger 
touches  it  the  patient  winces  and  complains  of  pain. 
These  painful  sensations  are  most  acute  when  the  ovary 
itself  is  touched,  but  they  are  also  evoked  when  the  neck 
of  the  uterus  is  pressed,  because  the  ovary  is  then 
squeezed  between  the  uterus  and  rectum. 

ii.   Retroflexion  of  the  uterus. — When    the    uterus  is 


Prolapse  of  the  Ovary.  31 

acutely  retroflexed  the  ovaries,  become  displaced  and 
sometimes  fixed  to  the  floor  of  the  recto-vaginal  pouch 
by  adhesions. 

iii.  Enlaj-ged  ovaries. — When  an  ovary  is  enlarged, 
in  consequence  of  a  solid  or  cystic  tumour  of  moderate 
dimensions,  its  weight  will  cause  it  to  fall  upon  the  floor 
of  the  recto-vaginal  pouch  ;  the  presence  of  a  small 
parovarium  cyst  will  produce  a  similar  displacement. 

The  clinical  bearing  of  displacements  of  the  ovary 

UTERUS 
TUBE 


FRINGES 


CERVIX 


Fig.    8.— Uterus,  Tubes,  and  Ovaries  of  an  Infant  one  month  old. 
Natural  size. 

from  various  causes  will  require  careful  discussion  in  sub- 
sequent sections  of  the  book. 

Alterations  in  shape  of  ovary  at  diflerenl 
periods  of  life. — The  variations  in  the  shape  of  the 
ovary  from  infancy  to  old  age  are  very  marked.  In  the 
foetus  at  birth  the  ovary  is  an  elongated  body,  resembling 
in  shape  a  miniature  but  somewhat  flattened  cucumber, 
lying  parallel  with  the  Fallopian  tube  ;  not  infrequently 
its  borders  are  crenated,  and  sometimes  a  longitudinal 
furrow  is  present  on  its  free  surface.  The  ovary  of  an 
infant  a  month  old  is  represented  of  natural  size  in  Fig.  8. 

The  infantile  form  of  ovary  gradually  changes,  and 
at  puberty  it  has  become  transformed  into  the  character- 
istic olive-shaped  gland,  indicative  of  the  sexually  mature 
female.     From  the  accession  of  puberty  until  the  forty-fifth 


32 


Diseases  OF  the  Ovaries. 


year  the  general  contour  of  the  ovary  remains  undis- 
turbed, but  the  smoothness  of  the  surface  is  marred  by 
scars,  the  effects  of  repeated  lacerations,  caused  by  the 
rupture  of  mature  follicles.  In  rare  instances  the  infantile 
shape  of  the  ovary  may  be  retained,  especially  in   the 


OVARY 


Fig.  9.  —  Ovary  and  Tube  of  a  Woman  68  years  of  age.     Natural  size. 


malformation  known  as  taiicorn  icterus.  In  this  condition 
— more  fully  considered  subsequently — one-half  the 
uterus,  with  the  tube  and  ovary,  proceeds  to  full  deve- 
lopment, but  the  opposite  half  remains  stunted,  or 
rudimentary.  In  these  specimens  the  ovary  generally 
retains  throughout  life  its  infantile  shape. 

From  the  age  of  forty-five  onward  the  ovary  begins  to 
dimmish  in  size.  This  alteration  is  accompanied  by 
arrest  of  menstruation.     As  the  organ  shrinks  the  surface 


Atrophy  of  the  Oi'arv.  33 

becomes  irregular,  and  often  marked  widi  deep  wrinkles. 
At  the  same  time  profound  alterations  arc  taking  place 
within  the  gland,  for  the  ova  and  ovarian  follicles  gra- 
dually disappear,  until,  in  very  advanced  life,  nothing  is 
left  but  a  corrugated  body,  consisting  of  fibrous  tissue, 
traversed  by  a  few  blood-vessels  (Fig.  9). 

The  alteration  in  the  size  of  the  organ  may  be  best 
expressed  by  giving  the  difference  in  weight.  The  ovary 
of  a  healthy  woman  of  twenty  years  weighs,  on  an 
average,  100  grains  ;  in  an  old  woman  of  seventy  years 
it  may  weigh  only  15  grains. 

The  uterus  and  Fallopian  tubes  undergo  a  corre- 
sponding diminution  in  size,  and  the  mucous  membrane 
atrophies. 

Atrophy  of  the  ovary. — The  senile  changes  just 
described  may  be  regarded  as  physiological  atrophy ; 
w^hen  they  occur  at  an  early  period  in  the  sexual  life  of  a 
woman,  they  are  then  described  as  pathological.  Our 
knowledge  of  premature  atrophy  of  the  ovary  is  not  very 
precise,  and  reliable  accounts  of  the  microscopical 
appearances  of  atrophied  ovaries  are  very  few. 

Doran*  described  in  detail  a  case  of  atrophy  of  the 
ovaries,  associated  with  deficient  development  of  the 
uterus  and  atresia  of  the  external  os,  in  a  woman  thirty- 
eight  years  of  age,  who  became  insane  a  few  months 
before  her  death. 

The  uterus  preserved  its  infantile  shape  ;  the  Fal- 
lopian tubes  were  normal.  The  right  ovary  was  two 
inches  long  and  a  quarter  of  an  inch  wide.  The  left 
was  an  inch  and  a  half  long.  On  microscopic  examina- 
tion no  trace  of  ovarian  vesicles  could  be  detected. 
In  shape  these  ovaries  preserved  the  infantile  type. 

An  example  of  premature  atrophy  of  the  ovaries  from 

*   Trans.  Obstet.  Sor.,  London,  vol.  xxi,  p.  253. 
D 


34 


Diseases  of  the  Ovaries. 


a  woman  thirty-nine  years  of  age  is  represented  in 
Fig.  lo.  The  irregular  exterior  resembles  the  convolu- 
tions on  the  surface  of  an  infant's  cerebrum. 

Ovaries  similar  to  the  specimen  in  Fig.  lo  are  not 
infrequently  described  as  cirrhotic,  probably  because  the 
ultimate  effect  upon  the  proper  tissue  of  the  ovary  is 
similar  to  that  seen  in  hepatic,  renal,  and  pulmonary 
cirrhosis  :  viz.  the  overgrowth  of  fibrous  tissue  destroys 


BAND 


SEAT  OF  STRICTURE 


■RINGES 
Fig.  lo.— Atrophied  and  Crenate  Ovary  from  a  Woman  39  years  of  age. 

the  secreting  or  proper  tissue  of  the  liver,  kidney,  or 
lung,  as  the  case  may  be.  The  great  difterence  in 
fibrosis  of  the  ovary  as  compared  with  this  change  in 
other  organs  is,  that  in  the  ovary  the  thickening  of  the 
albuginea  and  the  overgrowth  of  the  connective  tissue 
of  the  stroma  show  no  evidence  of  inflammation.  In 
cirrhotic  livers  the  interstitial  tissue  is  infiltrated  with 
small  round  cells,  but  in  cirrhotic  (or  fibroid)  ovaries  this 
is  not  the  case  even  when  this  change  occurs  in  the 
ovaries  of  women  who  also  have  cirrhotic  livers. 

The  changes  described  as  cirrhosis,  or  fibrosis  of  the 
ovaries,  occurring  in  women  between  twenty  and  forty 


Atrophy  of  the  OrARV.  35 

years  of  age,  require  a  fuller  investigation  than  they  have 
yet  received.  Even  the  causes  which  produce  the  change 
are  very  imperfectly  understood  ;  but  the  condition  is 
said  to  follow  typhoid  fever,  the  exanthemata,  rheumatism, 
and,  Dr.  Matthews  Duncan  suggested,  alcoholism. 

The  results  produced  by  the  change  are  dysineii- 
07'rhQia  and  sterility. 

Atrophy  of  the  ovary  is  sometimes  observed  when  the 
organ  is  compressed  by  a  large  parovarian  cyst  or  a 
myoma  of  the  uterus.  The  gland  is  sometimes  found 
flattened  and  compressed  like  a  leaf.  On  microscopical 
examination  nothing  is  seen  but  fibrous  tissue. 

Oophoritis  and  perioophoritis,  acute  and 
chronic,  are  so  constantly  associated  v\dth  salpingitis,  and 
in  nearly  all  cases  are  secondary  to  it,  that  the  subject 
will  be  treated  in  the  section  devoted  to  diseases  of  the 
tubes.  There  is,  however,  one  form  of  perioophoritis  which 
needs  mention  here.  When  a  woman  has  suffered  from 
a  combination  of  parametritis  and  perimetritis,  the  serous 
covering  of  the  ovary  and  Fallopian  tube  on  one  or  both 
sides  becomes  implicated.  As  the  inflammation  subsides 
the  ovary  and  tube,  glued  together  by  the  adhesive  in- 
flammation, become  permanently  fixed  to  the  posterior 
aspect  of  the  broad  ligament  and  to  each  other  by  dense 
adhesions.  This  should  be  remembered,  or  the  trouble 
may  be  erroneously  attributed  to  salpingitis.  Such  a 
condition  is  sometimes  denominated  perioophoritis. 


I)   2 


36 


CHAPTER  IV. 

THE    PELVIC    PERITONEUM. 

For  a  correct  appreciation  during  life  of  the  morbid 
anatomy  of  the  ovaries  and  Fallopian  tubes  it  is  neces- 
sary to  study  in  some  detail  the  relation  of  the  peritoneum 
to  the  pelvic  organs. 

The  peritoneum  as  it  descends  from  the  posterior 
wall  of  the  abdomen  enters  the  cavity  of  the  true  pelvis, 
covers  the  anterior  face  of  the  sacrum  and  the  first  part 
of  the  rectum  ;  it  gradually  leaves  the  sides  of  the  second 
part  of  the  rectum,  and  passing  on  the  upper  half-inch 
of  the  posterior  wall  of  the  vagina,  is  prolonged  upwards 
on  the  posterior  surface  of  the  uterus.  After  covering 
the  fundus,  it  descends  on  the  anterior  face  of  the  uterus 
and  leaves  it  to  cover  the  posterior  surface  of  the  bladder, 
and  ascends  on  the  posterior  aspect  of  the  anterior 
abdominal  wall. 

The  fold  formed  by  the  peritoneum,  as  it  is  reflected 
over  the  uterus  and  Fallopian  tubes,  is  known  as  the 
mesometrium,  or  broad  ligament.  Strictly  the  broad 
ligament  is  a  continuous  fold  of  peritoneum,  but  for 
clinical  purposes  it  has  been  found  convenient  to  regard 
it  as  consisting  of  two  halves — usually  referred  to  as  the 
right  and  left  broad  ligaments.  These  folds  are  directly 
continuous  laterally  with  the  peritoneum  lining  the  iliac 
fossse,  and  on  the  right  side  with  the  serous  covering  of 
the  caecum  and  its  appendix. 

The  recess  in  the  peritoneum  between  the  uterus  and 
rectum  is  known   as  the  recto-vaginal  pouch  (pouch  of 


The  Broad  Ligaments.  37 

Douglas),  and  that  between  the  uterus  and  bladder  the 
uterO'Vesical  pouch. 

Of  the  two  pouches,  the  recto-vaginal  is  the  deeper, 
and  extends  lower  on  the  left  than  the  right  side. 

Champneys*  has  described  a  case  in  which  he  found 
a  diverticulum,  large  enough  to  receive  and  conceal 
the  first  joint  of  the  middle  finger,  at  the  bottom  of 
the  recto-vaginal  pouch  :  its  lowest  point  being  one  inch 
and  a  half  below  the  level  of  the  external  os. 

In  cases  of  bicornuate  uteri  in  the  human  female  of 
the  variety  uterus  bicornis  unicollis,  a  median  vertical  fold 
of  peritoneum  divides  the  recto-vaginal  pouch,  and  con- 
tinues forward  between  the  uterine  cornua  on  to  the 
posterior  aspect  of  the  bladder,  thus  dividing  the  utero- 
vesical  pouch  into  two  lateral  shallow  depressions. 

The  degree  to  which  the  pelvic  organs  are  invested 
by  the  peritoneum  varies  much,  and  as  this  has  important 
relations  in  determining  the  course  of  fluid,  such  as  pus 
and  blood,  it  is  necessary  to  study  it.  It  has  already 
been  mentioned  that  the  first  part  of  the  rectum  is 
almost  completely  covered,  whilst  the  second  part  is  only 
covered  on  its  anterior  surface.  The  uterus  is  covered 
behind  and  in  front,  whilst  its  sides  are  in  relation  with  the 
narrow  connective  tissue  tract  of  the  mesometrium.  The 
vagina  is  only  immediately  in  relation  with  the  peritoneum 
by  the  upper  half-inch  of  its  posterior  cul-de-sac.  The 
bladder  is  covered  on  that  portion  of  its  posterior  surface 
situated  above  a  line  drawn  across  the  entrance  of  the 
ureters. 

The  subserous  tissue  varies  in  quantity  in  different 
situations.  Over  the  sacrum  it  is  very  lax,  and  occa- 
sionally one  of  the  kidneys  is  situated  in  the  hollow  of 
this  bone,  and  the  laxity  of  the  tissue  will  allow  of  its 

*   Trans.  Obstei.  Soc,  London,  vol.  xx.  p.  124. 


38  Diseases  of  the  Oi'aries. 

free  movement  up  and  clown  or  from  side  to  side.  In 
front  of  the  bladder  the  tissue  is  very  lax,  and  capable  of 
division  into  two  layers  ;  the  space  between  them  is  some- 
times called  the  cave  of  Retzius.  In  the  adult  a  large 
plexus  of  veins  lies  in  the  vesical  wall  of  this  imaginary 
cave. 

Each  broad  ligament  consists  of  two  layers  of  peri- 
toneum slightly  separated  by  connective  tissue  and 
involuntary  muscle  tissue.  Each  contains  the  Fallopian 
tube,  the  ovary,  parovarium  with  Gartner's  duct,  the 
ligament  of  the  ovary,  the  ureter,  numerous  blood-vessels, 
lymphatics,  and  nerves.  In  order  to  appreciate  the 
pathological  relations  of  the  broad  ligament,  it  is  necessary 
to  indicate  the  positions  of  the  various  organs  contained 
between  its  layers.  When  the  parts  are  stretched  out  the 
Fallopian  tube  will  be  found  to  occupy  the  free  border, 
and  to  be  attached  by  the  tubo-ovarian  ligament  to  one 
extremity  of  the  ovary.  The  opposite  pole  of  the  ovary 
is  connected  by  the  ligament  of  the  ovary  to  the  side 
of  the  uterus.  The  upper  part  of  the  broad  ligament  is 
called  the  mesosalpinx^  and  is  included  between  the 
Fallopian  tube,  the  tubo-ovarian  ligament  and  the  ovary 
with  its  proper  ligament.  It  contains  between  its  layers 
the  parovarium  and  the  associated  portion  of  Gartner's 
duct,  the  ovarian  artery,  a  plexus  of  veins,  and,  passing 
from  its  anterior  and  inner  part  close  to  the  uterine  end 
of  the  Fallopian  tube,  the  round  ligament  of  the  uterus. 

The  round  ligaments  arise  from  the  upper  angles  of 
the  uterus  anterior  to  the  Fallopian  tubes ;  each  passes 
obliquely  forward  to  gain  the  internal  abdominal  ring,  in 
order  to  traverse  the  inguinal  canal.  A  fold  of  peritoneum, 
directly  continuous  with  the  anterior  layer  of  the  broad 
ligament,  partially  invests  these  muscular  cords,  and  forms 
a  narrow  pouch  in  the  inguinal  canal,  known  as  the 
canal  of  Nuck,  generally   obliterated  in  the  adult.      It 


The  Broad  Ligaments. 


39 


corresponds  in  situation  and  mode  of  formation  with  tlie 
funicular  [)ouch  of  peritoneum  in  the  male.  These 
peritoneal  pouches  are  formed  about  the  period  at 
which  the  ovaries  descend  from  their  lumbar  position, 
near  the  kidneys,  to  their  acquired  situation,  in  the 
pelvis. 

Two  strands  of  tissue,  the  iitero-sacral  ligaiuefits^  pass 
from  the  sides  of  the  sacrum,  as  high  as  the  body  of  the 
second  sacral  vertebra,  to  the  lateral  aspect  of  the  supra- 
vaginal portion  of  the  neck  of  the  uterus."  They  give  rise 
to  the  peritoneal  folds  on  each  side  of  the  pelvis,  which 
form  definite  limits  to  the  recto-vaginal  pouch. 

The  portion  of  the  broad  ligament  below  the  meso- 
salpinx contains  the  ureter,  some  large  veins,  the  uterine 
artery  as  it  passes  from  the  iliac  trunk  to  gain  the 
uterus,  and  the  fibrous  cord  representing  the  obliterated 
hypogastric  artery.  The  lower  part  of  the  broad  ligament 
differs  from  the  mesosalpinx  in  that  the  two  layers  are 
more  separated  from  each  other,  the  connective  tissue 
is  of  looser  texture  and  allows  fluid  accumulations  on 
one  side  to  pass  round  the  back  of  the  uterus  into  the 
opposite  half  of  the  broad  ligament,  and,  on  the  left  side, 
an  abundant  haemorrhage,  or  a  fluid  effusion,  will  make 
its  way  around  the  second  part  of  the  rectum.  When 
extensive,  such  effusions  will  raise  up  the  anterior  layer  of 
the  broad  ligament,  and  present  at  the  level  of  Poupart's 
ligament,  especially  in  the  neighbourhood  of  the  inguinal 
canal ;  occasionally  the  fluid  will  pass  round  the  bladder 
and  invade  the  connective  tissue  in  the  cave  of  Retzius. 
The  laxity  of  the  subserous  tissue  near  the  pelvic 
brim   will    allow    pus    collected    around   a  suppurating 


*  For  a  detailed  and  historical  account  of  the  utero-sacral  ligaments 
and  the  cave  of  Retzius,  consult  Delbet,  Des  Suppurations  Pelviennes 
ckez  la  Femnie  I  Paris,  1891, 


40  Diseases  of  the  Ovaries. 

or  sloughing  vermiform  appendix  occasionally  to  make 
its  way  between  the  layers  of  the  broad  ligament ;  this, 
however,  can  only  happen  when  the  pus  finds  its  way 
between  the  layers  of  the  mesocsecum. 

The  facility  with  which  the  anterior  layer  of  the 
broad  ligament  can  be  stripped  up,  except  when  firmly 
fixed  by  old  inflammatory  adhesions,  explains  the  fre- 
quency with  which  pelvic  abscess  points  in  the  neigh- 
bourhood of  Poupart's  ligament.  Large  tumours  growing 
from  the  side  of  the  uterus,  or  from  the  connective  tissue 
of  the  broad  ligament,  or  a  foetus  developing  between  its 
layers,  will  in  some  instances  raise  up  the  anterior  layer, 
and  insinuate  themselves  between  the  peritoneum  and 
the  front  wall  of  the  abdomen.  The  fact  that  the  tissue 
in  the  mesometrium  contains  unstriped  muscle  fibre  is  of 
some  importance,  as  it  plays  a  part  i-n  several  morbid 
conditions.  It  is  also  important  to  remember  that, 
whereas  fat  is  present  and  usually  abundant  in  the  sub- 
serous tissue,  it  is,  as  a  rule,  wanting  in  the  mesometrium. 
Occasionally,  however,  fat  is  found  in  this  situation,  and 
has  been  known  to  be  so  abundant  as  to  form  a  so-called 
fatty  tumour. 

The  peculiarity  of  cysts  and  tumours  in  their  be- 
haviour to  the  broad  ligament  will  be  more  fully  discussed 
afterwards.  AVe  must,  however,  devote  here  some 
space  to  the  consideration  of  the  anatomy  of  the 
mesosalpinx. 

It  has  already  been  mentioned  that  the  Fallopian  tube 
lies  in  the  free  border  of  the  broad  ligament,  and  is 
invested  on  two-thirds  of  its  circumference  by  peritoneum. 
The  muscle  tissue  of  the  broad  ligament  is  directly, 
though  loosely,  continuous  with  the  muscle  tissue  of  the 
wall  of  the  tube.  That  the  tube  is  loosely  connected  to 
its  peritoneal  coat  is  shown  by  the  fact  that  it  moves  to  a 
certain   extent   independently  of  its  serous  investment. 


The  Broad  Ligaments.  41 

For  instance,  in  the  fcetus  near  the  time  of  birth,  and  for 
a  year  or  two  afterwards,  the  Fallopian  tubes  are  very- 
tortuous.  This  tortuosity,  or  angulation  as  it  is  some- 
times called,  is  due  to  the  tube  increasing  in  length  at  a 
greater  rate  than  the  mesometrium.  When  the  uterus 
rises  out  of  the  pelvis  during  pregnancy,  the  tubes  are 
elongated  and  hypertrophied ;  when  involution  follows 
delivery  at  term,  and  the  parts  sink  to  their  usual  position, 
the  tubes  present  for  a  time  an  irregular  twisted  appear- 
ance. Again,  when  the  tubes  inflame,  they  lengthen,  and 
the  increase  in  length  manifests  itself  in  angulation. 

The  relation  of  the  ovaiy  to  the  mesometrium  is  very 
different  to  that  of  the  Fallopian  tube.  When  the  parts 
are  examined  from  the  front  aspect  the  ovary  is  not  seen, 
w^hereas  on  the  posterior  aspect  it  is  a  conspicuous  object. 
This  is  due  to  the  fact  that,  whereas  the  tube  is  invested 
by  both  layers  of  the  mesometrium,  the  ovary  is  only 
covered  by  the  posterior  layer. 

The  ai'teries  lying  betw^een  the  layers  of  the  broad 
ligaments  are  numerous  and  important.  The  largest  is 
the  7iterine  artery,  which  is  given  off  by  the  anterior 
division  of  the  internal  iliac  ;  it  runs  under  the  peritoneum 
towards  the  cervix  of  the  uterus,  and  then  turns  upwards 
as  soon  as  it  gets  between  the  folds  of  the  broad  ligament, 
and  runs  for  a  space  by  the  side  of  the  uterus,  nearer  the 
posterior  than  the  anterior  surface,  and  as  it  approaches 
the  fundus  inosculates  with  the  ovarian  artery.  As  the 
artery  ascends  it  gives  off  branches  to  the  anterior  and 
posterior  surface  of  the  uterus  which  anastomose  with 
similar  branches  from  the  uterine  artery  of  the  opposite 
side. 

The  ovarian,  like  the  spermatic  artery  in  the  male, 
arises  from  the  abdominal  aorta  below  the  renal  vessels, 
and  runs  downwards  to  pass  between  the  layers  of  the 
broad  ligament  at  the  brim  of  the  pelvis,  then  makes  its 


42  Diseases  oe  the  Oi'aries, 

way  to  the  side  of  the  uterus,  near  the  fundus,  to  inoscu- 
late with  the  uterine  artery.  In  its  course  between  the 
folds  of  the  ligament  it  distributes  numerous  branches  to 
the  ovary,  Fallopian  tube,  fundus  of  the  uterus,  con- 
nective tissue  in  the  broad  ligament,  and  gives  a  branch 
which  anastomoses  with  a  small  vessel  derived  from  the 
deep  epigastric  artery  which  is  conducted  along  the 
round  ligament. 

The  veins  follow  much  the  same  course  as  the 
arteries  to  which  they  belong,  but  the  various  branches 
of  the  ovarian  vein  are  very  large,  and  when  the  ovary 
forms  a  large  cyst,  or  the  uterus  is  occupied  by  a  myoma, 
or  is  gravid,  these  veins  become  greatly  dilated.  The 
ova7'ian  veins  are  situated  mainly  in  the  mesosalpinx, 
where  they  give  rise  to  the  pavipinifoi-ni  plexus^  which  is 
homologous  with  the  plexus  of  the  same  name  in  the 
male,  and,  like  it,  represents  the  persistent  veins  of  the 
Wolffian  body.  Near  the  outer  end  of  each  broad 
ligament  the  veins  coalesce,  and  a  single  trunk  finally 
issues  to  terminate  on  the  right  side  in  the  inferior  vena 
cava,  and  on  the  left  side  in  the  renal  vein. 

The  long  course  which  the  ovarian  arteries  and  veins 
pursue  is  explained  by  the  fact  that  in  the  early  embryo 
the  genital  glands  in  each  sex  lie  in  the  loin,  in  rela- 
tion with  the  kidneys,  and  originally  received  their  blood 
supply  from  the  immediately  adjacent  aorta ;  as  the 
glands — testes  or  ovaries — descended  into  the  scrotum, 
or  pelvis,  the  arteries  and  veins  became  elongated. 

THE    BLADDER    AND    URETERS    IN    THE    FEMALE. 

The  bladder  is  so  directly  concerned  in  the  differ- 
ential diagnosis  of  abdominal  tumours  and  in  operative 
procedures  in  the  pelvis,  and  is,  with  the  ureters,  so  often 
in  danger  of  injury,  and  not  infrequently  these  struc- 
tures are  actually  seriously  damaged,  that  it  is  necessary 


The   Ureters  and  Bladder.  -43- 

to  briefly  summarise  the  chief  relations  of  the  parts.  Tliis 
is  not  difficult,  as  the  anatomy  of  the  bladder  and  ureters 
in  its  surgical  bearings  has  been  very  carefully  investi- 
gated. Except  when  considerably  distended,  the  bladder 
lies  behind  the  pubes,  and  does  not  rise  so  rapidly  out  of 
the  pelvis  as  in  the  male.  When  over-distended  it  forms 
an  oval  cyst,  situated  exactly  behind  the  middle  line  of 
the  anterior  abdominal  wall.  Sometimes  it  is  drawn  up- 
wards, and  spread  out  laterally  over  the  anterior  surface 
of  a  uterine  tumour.  As  the  bladder  distends  with  urine 
and  extends  upwards  into  the  abdomen,  it  displaces  the 
peritoneum  and,  in  some  cases  in  which  the  bladder  is 
permanently  drawn  upwards  by  a  tumour,  it  will  lie  in 
front  of  the  peritoneum  even  when  empty,  and  has,  under 
such  conditions,  been  opened  by  the  knife  of  an  incautious 
surgeon,  unaware  of  the  possibility  of  this  alteration  in  its 
position.  The  eye  of  the  experienced  surgeon  usually 
prevents  this  accident,  for  the  muscular  coat  of  the 
bladder,  when  deprived  of  its  serous  coat,  has  a  very 
characteristic  appearance. 

The  tireters  enter  the  pelvis  near  the  point  of  divi- 
sion of  the  common  iliac  arteries — sometimes  a  little 
posterior,  sometimes  a  little  anterior  to  the  point  of  bifur- 
cation. Each  ureter  dips  down  the  posterior  wall  to 
near  the  ischial  spine  :  from  this  point,  still  descending, 
they  pass  forward  and  inward,  lying  in  the  connective 
tissue  at  the  base  of  the  broad  ligament,  and  pass  within 
half  an  inch  of  the  neck  of  the  uterus  ;  descending  along 
the  side  and  upper  part  of  the  vagina,  they  turn  to  the 
middle  line  and  enter  the  posterior  wall  of  the  bladder. 
Whilst  the  ureters  are  passing  from  the  posterior  wall  of 
the  pelvis,  to  gain  the  side  of  the  neck  of  the  uterus,  they 
are  crossed  by  the  uterine  artery.  In  the  operation  of 
ovariotomy  a  ureter  may  be  damaged  when  the  cyst  is 
fixed  by  firm  adhesions  near  the  brim  of  the  pelvis. 


44 


CHAPTER  V. 


OOPHORITIC     CYSTS. 


It  has  already  been  pointed  out  that  the  ovary  consists 
of  an  egg-bearing  portion,  the  oophoron  and  a  region  in 
which  ova  are  not  found,  termed  \\\q  paroophoro7i.  If  to 
these  the  parovarium  be  added,  we  can  arrange  the  cysts 


Fig.  II. — Diagram  representing  the  Cyst  Regions  ot  the  Ovary. 
A,  Oophoron  ;  E,  paroophoron  ;  C,  parovarium  ;  K,  Kobelt's  tubes ;  G,  Gartner's  duct. 


which  arise  in  each  region  in  three  classes,  for  they  pre- 
sent distinctive  features.  The  relation  of  the  three  cyst 
regions  to  each  other  is  diagrammatically  shown  in 
Fig.  II. 

The  cysts  peculiar  to  each  region  will  be  considered 


Unilocular   Cysts. 


45 


under  three  headings: — (i)  Oophoritic  cysts;  (2)  Paro- 
ophoritic cysts  j  and  (3)  Parovarian  cysts. 

Oophoritic  Cysts. 
For    cHnical    convenience    cysts    of    the    oophoron 
may  be  studied    in    two   groups  : — i.   Unilocular  cysts 
2.  Multilocular  cysts 


Fig.    12. — A,    Incipient   Oophoritic   Cyst,      b,   Paroophoron. 
F,  Fallopian  Tube.     Natural  size. 


r.    Parovarium. 


I.  Unilocular  cysts. — The  term  unilocular  has 
mainly  a  clinical  significance :  it  is  rare  to  find  an  oophoritic 
cyst  with  only  one  cavity.  A  careful  examination  of  such 
specimens  will  usually  reveal  numerous  smaller  loculi  in 
the  walls,  or  imperfect  septa  and  bands  of  tissue  passing 
from  one  part  of  the  cavity  to  another  indicate  that  the 
cyst  was  originally  compound.  Many  of  the  large  one- 
chambered^  cysts,  described  by  early  ovariotomists  as 
ovarian,  in  many  instances  originated  in  the  parovarium. 


46  Diseases  of  the  Ovaries. 

An  incipient  oophoritic  cyst  is  shown  in  Fig.  1 2.  In 
this  specimen  it  was  easy  to  demonstrate  that  the  cavity 
was  an  enlarged  ovarian  folHcle,  for  its  walls  were  fur- 
nished with  a  well-marked  membrana  granulosa.  In  a 
very  early  stage  it  is  easy  to  demonstrate  the  relation  of 
such  a  cyst  to  the  oophoron.  As  the  cyst  enlarges  it 
causes  rapid  absorption  of  the  paroophoron,  and  the 
region  in  which  it  arose  is  then  not  so  easily  demon- 
strable. 

It  is  only  by  patiently  waiting  for  opportunities  of 
securing  cysts  in  very  early  stages  that  it  is  possible  to 
elucidate  their  mode  of  origin.  Much  of  the  confusion 
which  obscures  the  pathology  of  this  question  is  due  to 
the  fact  that  most  investigators  have  devoted  their  atten- 
tion mainly  to  large  cysts. 

Occasionally  we  may  be  so  fortunate  as  to  secure  a 
cyst  of  some  size  which  has  not  destroyed  the  relation 
of  the  parts.  Such  a  specimen  is  shown  of  natural  size 
in  Fig.  13.  The  evening  before  the  operation  the  patient 
commenced  to  menstruate  ;  when  the  cyst  was  drawn  up 
from  the  pelvis  a  small  rounded  aperture  was  noted  in 
the  peritoneal  covering  from  which  a  few  drops  of  blood 
issued.  Examination  of  the  parts  showed  this  to  be  a 
recently  ruptured  follicle. 

The  tissue  hning  the  interior  of  oophoritic  cysts  varies 
greatly.  In  cysts  of  the  size  shown  in  Fig.  12  it  is 
membrana  granulosa;  in  cysts  of  the  size  shown  in 
Fig.  13,  or  even  three  times  larger,  the  walls  will  be 
covered  with  stratified  epithelium.  In  large  cysts  con- 
taining several  pints,  or  even  two  or  three  gallons,  of 
fluid,  the  walls  will  be  found  to  consist  entirely  of  fibrous 
tissue ;  no  epithelium  can  be  detected.  It  is  impossible 
to  state  definitely  the  size  of  a  cyst  in  w^hich  epithelium 
disappears.  The  absence  of  epithelium  is  due  to  atrophic 
changes,    the    consequence    of    the    continual    pressure 


OoPHORiTic  Cysts. 


47 


exerted    by   the   accumulating   fluid.     Precisely    similar 


-^ 


TUBE 


Fig.   13. — Oophoritic  Cyst.      Natural   size.     (After  H.   W.  Freeman.)     On  its 

surface  is  a  recently  ruptured  follicle. 

K,  Fimbriated  Kobeit's  tube. 

changes  may  be  studied    in    the  mucous  membrane  of 
greatly  distended  gall-bladders. 


48  D/SEASKS    OF    THE    O I' ARIES. 

In  large  cysts,  although  the  main  cavity  is  destitute 
of  epithelium,  the  smaller  loculi  and  recesses  will  present 
a  lining  of  typical  columnar  epithelium. 

Occasionally  unilocular  oophoritic  cysts  are  filled 
with  fluid  identical  in  its  physical  and  chemical  characters 


f|- 


-4-\  r. 


fe^i^^fiv^^-vn^^H  ^ 


1^^  lilt; 


'It 

:^ 

J) 

i 

'■^ 

) 

i 

4 

J 

''■^vwiiivrS;.;:, 


.••..//.la'V-"'  '^/,. 


Fig.  14.— Section  of  Mucous  Membrane  from  an  Ovarian  Cj'St.     Magnified. 

with  mucus.  Such  cysts  are  sometimes  lined  with  soft 
velvety  membrane,  raised  here  and  there  into  elevations 
resembling  the  cotyledons  of  the  uterus  of  a  ruminant 
when  pregnant.  The  microscopical  characters  of  the 
tissue  are  exactly  similar  to  mucous  membrane ;  the 
epithelium  covering  it  is  columnar  in  type,  and  dips  below 
the  surface,  to  form  complex  mucous  glands. 

The    credit   of   recognising    mucous    membrane    in 


CvsTS  WITH  Mucous  Membrane. 


49 


ovarian  cysts  belongs  to  Poupinel.*  My  observations 
were  made  quite  independently,  and  in  ignorance  of 
Poupinel's  paper.     As  will  be  shown  in  the  next  section, 


Fig,  15.— Unilocular  0\arian  Dermoid.     Natural  s'ze.     {Trans.  Obstet. 

Soc,  London.) 

O,  Dermoid;  P,  paroophoron;  P',  parzvarium. 

mucous  membrane  occurs  more  frequently  in  multilocular 
than  in  unilocular  cysts  (Fig.  14). 

In  a  certain  proportion  of  unilocular  cysts  the  walls 
are  lined  with  skin,  furnished  with  hair,  sebaceous  and 
sweat    glands,     sometimes     teeth     and    other     dermal 

*  Ay-chives  dc  Physiologic,  Series  iii.  voL  ix. 


50  Diseases  of  the  Ovaries. 

appendages.  A  specimen  of  this  is  sketched  in  Fig.  15. 
This  cyst  is  of  some  interest,  for  it  is  of  the  size  of  an 
egg  and  strictly  Hmited  to  the  oophoron  ;  it  is,  as  has 
been  pointed  out  earUer  in  this  chapter,  unusual  to  find 
the  paroophoron  intact  when  an  oophoritic  cyst  attains 
such  proportions  as  in  the  specimen  from  which  this 
sketch  was  made. 

The  variations  in  the  Hning  membrane  and  contents  of 
unilocular  oophoritic  cysts  may  be  summarised  thus  : — 

(i)  Epithehum  is  usually  absent  in  large  cysts. 

(2)  A  layer  of  stratified  cells  is  present  in  cysts  of 

moderate  size. 

(3)  The  interior  may  be  clothed  with  mucous  mem- 

brane, furnished  with  glands  and  covered  with 
columnar  epithelium. 

(4)  Skin,  with  its  various  appendages,  may  line  the 

cyst  wholly  or  in  part. 

(5)  In  size  they  may  vary  from  an  ordinary  ovarian 

follicle  to  a  cyst  containing  gallons  of  fluid. 

(6)  The  contents  may  be  a  thin  colourless  fluid  or 

thick    tenacious   mucus.     The    fluid    may   be 

grumous,   from  admixture  with  blood.     When 

skin  lines  the  cyst  it  will  contain  pultaceous 

matter  formed  of  shed  epithelium,  sebum  from 

the  glands,  epithelial  debris^  and  shed  hair. 

2.  Mnltilocular  cysts.— In  this  group  the  various 

tumours  are  for  the  most  part  made  up  of  a  congeries  of 

cysts    of  varying    size,    so    that    in   typical   specimens 

a  section  carried  through  the  more  solid    parts  of  the 

tumour  has  an   appearance    not   unlike   a   honeycomb. 

For  convenience  of  description  they  will  be  considered 

in  three  sets — 

{a)  Simple  multilocular  cysts. 

{b)  Adenomata. 

[c)  Multilocular  dermoids. 


MUL  TIL  OC  UL  A  R    C  J  '^  TS. 


51 


A  typical  specimen  will  be  described  to  illustrate 
each  variety,  but  it  must  be  remembered  that  they  pass 
by  insensible  gradations  one  into  the  other. 

A  very  early  stage  is  represented  in  Fig.  16.  The 
cysts  are  restricted  to  the  oophoron.  To  the  naked  eye 
and  with  the  microscope  such  cysts  are  indistinguishable 
from  normal  ovarian  follicles.     This  may  be  spoken  of 


Fig.  16.— Human  Ovary  in  section,  showing  a  Multilocular  Cyst  in  an  early  stage. 
a,  Obphoron  ;  b,  paroophoron  ;  P,  parovarium  ;  k,  Kobelt's  tubes;  F,  Fallopian  tube, 


as  the  indifferent  stage ;  from  this  small  beginning  the 
cysts  may  increase  in  size  until  a  tumour  is  produced  of 
such  large  dimensions  that  life  is  rendered  burdensome 
merely  on  account  of  the  mechanical  inconveniences  its 
presence  induces. 

As  the  ovary  increases  in  size,  the  various  loculi  may 
retain  a  simple  lining  of  flattened  epithelium  :  in  many  of 
the  cavities  it  disappears.  Frequently  the  epithelium 
exhibits  very  active  changes,  and  the  cysts  becom.e  occu- 
pied by  glandular  structures,  sometimes  of  great  com- 
plexity. Such  complex  cysts  are  occasionally  referred  to 
E  2 


52  DjSEASES    of    the    Ol^ARlES. 

as  multilociilar  glandular  cysts,  but  they  are  more  appro- 
priately termed  ovarian  adenomata^  and  it  is  by  the  latter 
term  that  they  will  be  designated  throughout  this  work. 

An  ovarian  adenoma  is  not  only  an  important,  but  an 
extremely  interesting,  variety  of  tumour.  As  a  rule,  it 
has  a  dense  fibrous  capsule,  and  the  surface  is  frequently 
lobulated.  These  tumours  attain  great  dimensions,  and 
are  composed  of  innumerable  cysts,  which  vary  in  size 
from  a  cavity  no  bigger  than  a  pea,  to  one  holding 
a  quart  or  more  of  fluid.  Critical  dissections  of  such 
cysts  enable  us  to  recognise  three  varieties  of  loculi.  In 
typical  specimens  a  honeycomb-like  mass  will  be  found 
projecting  into  some  of  the  larger  cavities,  and  occupying 
usually  one-third  of  its  circumference,  so  that  a  section 
of  the  cavity  resembles  a  signet-ring — such  are  called 
primary, — whilst  the  cavities  occupying  the  honeycomb 
portion  are  secondary  cysts,  and  are,  as  a  matter  of  fact, 
mucous  retention  cysts.  The  third  set  of  loculi  contain 
no  honeycomb-like  structures,  are  of  small  size,  and 
histologically  are  indistinguishable  from  distended  ovarian 
follicles.  The  relations  of  the  primary  and  secondary 
cysts  to  each  other  are  shown  in  Fig.  17. 

When  complex  cysts  of  this  character  are  quite  fresh, 
if  the  smaller  loculi  are  punctured  with  a  sharp  knife  and 
the  fluid  watched  as  it  flow^s  through  the  opening,  a  small 
opaque  body,  about  the  size  of  a  rape-seed,  will  often  be 
detected  escaping.  These  bodies  have  been  described 
as  ova.  Sometimes  many  of  the  cysts  will  project  upon 
the  surface  of  the  tumour,  having  made  their  w\ay  through 
the  capsule  by  absorption,  and  produce  a  resemblance 
not  unlike  a  colossal  bunch  of  grapes.  LawsonTait*  has 
described  cysts  of  this  character  as  Rokitansky's  tumour, 
and    refers   to    a    specimen    in    the    Royal    College    ot 

*  Diseases  of  the  Ovaries^  p.  174  ;  1883. 


OrA  RiA  N  Adeno.ua  ta  . 


53 


Surgeons'  museum.  Unfortunately,  even  with  the  aid  ot 
the  pathological  curator,  I  have  been  unable  to  identify  the 
specimen.    Mr.  Reeves  showed  a  specimen  at  the  British 


Fig.  17.— Portion  of  an  Ovarian   Adenoma,    showing  the  varieties  of  Locuh'. 

(Trans.  Obstet.  Soc,  London.) 

c.  Primary ;  d,  secondary. 

Gynaecological  Society,  which  Mr.  Lawson  Tait  identified 
as  a  typical  Rokitansky's  tumour.  I  had  the  opportunity 
of  examining  this  cyst.  It  was  a  typical  ovarian  adenoma, 
with  cysts  projecting  through  the  capsule. 


54 


Diseases  op  the  Ovaries. 


The  primary  cysts  in  their  early  stage  are  lined  with 
rich  columnar  epithelium,  and  in  that  portion  of  their 
circumference  which  corresponds  to  the  honeycomb  of 
larger  cysts  mucous  glands  are  found.  Indeed,  the 
lining  membrane  of  such  cysts  is  identical  with  mucous 


Fig.  i8. — Ovarian  Adenoma,  presenting  a  Cutaneous  Clump  (<^)  with  a  Tuft  of 
Hair  iji).     (Trans.  Obstet.  Soc,  Londo7i.) 

membrane.    Occasionally  a  lock  of  hair  may  be  detected 
sprouting  into  one  of  the  larger  loculi. 

The  museum  of  St.  Thomas's  Hospital  contains  an 
excellent  example  of  this.  The  specimen  is  mounted  in 
the  teaching  series  as  a  typical  multilocular  ovarian 
glandular  cyst  (adenoma).  Sprouting  from  a  small 
dermoid  patch  in  one  of  the  larger  loculi  is  a  tiny  tuft  of 
hair  (Fig.  i8). 


OrAKiAN  Jdenomata.  55 

From  multilocular  cysts  lined  with  mucous  membrane 
we  pass  to  those  which  possess  in  one  loculus  a  small 
tuft  of  hair^  to  others  which  present  skin  or  mucous 
membrane  furnished  with  hair,  sebaceous  or  sudori- 
parous glands,  unstriated  muscle  fibre,  fat,  and  teeth  in 
every  loculus. 

Occasionally  tumours  occur  presenting  three  distinct 


Fig.  19. — Transverse  Section  of  an  Ovarian  Tumour  from  a  Mare  ;  it  weighed 

eighty-four  pounds. 

A,  Oophoron  ;  E,  paroophoron  ;  F,  Fallopian  tube. 

types  of  cysts  :  that  is,  one  set  of  cysts  contains  skin, 
hair,  sebaceous  glands,  and  teeth ;  another  presents  only 
clusters  of  mucous  glands  and  mucous  cysts ;  and  the 
third  set  is  indistinguishable  from  ovarian  follicles. 

Thus,  as  in  the  case  of  unilocular  cysts,  it  is  impossible 
to  demarcate  between  adenomata  and  dermoids.  In 
specimens  without  glands  it  is  often  impossible  to 
determine  whether  the  lining  membrane  should  be 
classed  as  mucous  membrane  or  skin. 

Multilocular  cysts  with  dermoid  contents  are  of  such 


56  Djseases  of  the  Oi'aries. 

interest  that  a  special  chapter  will  be  devoted  to  their 
consideration. 

It  has  been  mentioned  that  in  the  human  ovary, 
when  cystic,  the  relation  between  the  oophoron  and 
paroophoron  is  quickly  destroyed.  In  some  mammals, 
especially  the  mare,  the  paroophoron  is  relatively  very 
large.  It  happens  that  when  the  ovary  of  the  mare  is 
cystic,  the  paroophoron  is  uninvaded  by  the  cysts,  even 
when  the  organ  is  much  enlarged.  Thus,  in  the  speci- 
men from  which  Fig.  19  was  obtained  the  tumour  weighed 
eighty-four  pounds ;  yet  on  transverse  section  it  was 
readily  observed  that  the  paroophoron  remained  quite 
distinct  from  the  egg-bearing  portion.  The  loculi  in  this 
large  ovary  were,  in  many  instances,  indistinguishable 
from  enlarged  ovarian  follicles  :  some  of  the  larger  spaces 
contained  mucous  membrane. 

The  malignancy  of  ovarian  adenomata  requires  careful 
investigation.  Evidence  is  accumulating  in  favour  of  the 
view  that  rapidly-growing  adenomata  of  the  ovary  may,  if 
the  loculi  rupture,  infect  the  peritoneum.  In  some 
isolated  cases  there  is  reason  to  believe  that  the  growth 
recurred  in  the  pedicle. 


57 


CHAPTER  VI. 

OVARIAN     DERMOIDS. 

The  adjective  dermoid  should  be  applied  to  cysts  of  the 
ovary  when  they  contain  skin  or  mucous  membrane. 
Frequently  dermoids  contain  both  these  structures.  The 
amount  of  skin  in  a  dermoid  varies  greatly  in  different 
cysts,  and  in  the  complexity  of  the  cutaneous  appendages 
with  which  it  may  be  furnished.  In  some  specimens  the 
wall  of  a  large  cyst  will  be  completely  covered  with  skin, 
whilst  in  others  it  will  be  restricted  to  a  small  area,  or 
even  be  confined  to  a  small  loculus  in  a  multilocular 
cyst. 

The  following  cutaneous  appendages  have  been  found 
in  ovarian  dermoids: — Hair,  sebaceous  glands,  sweat- 
glands,  teeth,  mammae,  horn,  nail,  bone,  unstriped 
muscle  and  tissue  histologically  identical  with  brain 
matter. 

The  hair  of  dermoids  varies  in  length,  colour,  and 
amount.  A  single  tuft  coiled  into  a  ball  and  mixed  with 
sebaceous  matter  is  not  infrequent,  and  may  attain  a 
length  of  twenty  inches.  Munde*  has  described  and 
figured  a  specimen  in  which  a  tuft  of  hair  in  an  ovarian 
dermoid  was  five  feet  long.  Occasionally  only  a  few 
hairs  are  found  scattered  on  the  cyst  wall,  or  the  hair 
may  be  rolled  into  balls  and  lie  free  in  the  cyst.  The 
colour  is  equally  capricious,  and,  as  a  rule,  differs  from 
that  on  the  exterior  of  the  individual.  The  hair  in 
such   cysts  changes  in  colour  with  age,  and  in  elderly 

*  Amer.  /ournal  of  Obstet.,  vol.  xxiv.  p.  854. 


58  Diseases  of  the  0 varies. 

persons  becomes  quite  white,  and  is  eventually  shed,  so 
that  these  cysts  become  actually  bald. 

Sebaceous  gla?ids  are  numerous  and  very  large  in 
size.  Occasionally  they  become  converted  into  retention 
cysts. 

Sweat  glands  are  not  so  frequent  as  the  sebaceous 
variety,  and  generally  occur  in  clusters. 

The  pultaceous  material  which  fills  these  cysts  is  a 
mixture  of  epithelial  debris,  sebum  from  the  sebaceous 
glands,  shed  hairs,  oil,  and  cholesterine. 

U?istriped  iiiusde  fibre  is  frequently  found  in  the  wall 
of  ovarian  dermoids,  but  the  striped  variety  is  very  rare. 

Bone  is  often  present,  either  in  loose,  ill-formed,  and 
shapeless  masses,  resembling  in  structure  that  found 
along  the  alveolar  borders  of  the  jaws,  or  as  irregular 
plates,  exceedingly  hard,  and  resembling,  as  Doran  sug- 
gests, the  facial  bones  of  an  osseous  fish. 

Ovarian  mamiiise. — It  is  not  uncommon  to  find 
in  the  interior  of  an  ovarian  dermoid  one  or  more  tags  of 
skin  resembling  a  nipple  associated  with  teeth  and  hair. 
Not  infrequently  these  nipple-like  processes  of  skin  are 
attached  to  more  or  less  rounded  projections  of  tissue, 
which  recall  in  a  striking  manner  the  shrunken  mammae 
of  a  woman  who  has  given  suck  to  many  children.  The 
nipple-like  processes  of  skin  are  imperforate,  and  beset 
with  large  sebaceous  glands.  In  other  cases  the  mammae 
may  be  plump  and  well-formed,  but  consist  of  fat  covered 
with  skin.  Even  in  such  a  case  no  ducts  or  gland  tissue 
occupy  the  substance  of  the  mass.  The  nipple  may 
be  surrounded  by  an  areola.  Such  are  called  psciido- 
uiaijinue  (Fig.  20), 

In  a  specimen  described  by  Shattock  the  nipple  was 
imperforate,  but  a  cyst  filled  with  colostrum  occupied  its 
base. 

The  most  complete  forms  of  ovarian  mammae  contain 


Op'arian  Mamm^.  59 

glandular  tissue,  which  communicates  with  the  cavity 
of  the  dermoid  by  means  of  ducts  which  traverse  the 
nipples. 

My  most  perfect  specimen  was  obtained  from  a 
dermoid  removed  by  Dr.  Bantock.  On  dissecting  the 
cyst,  which  was  as  large  as  a  cocoa-nut,  and  filled  with 


Fig.  20. —Ovarian  Dermoid,  with  a  pseudo-mamma.     (Museum,  Royal  College 

of  Surgeons. ) 

the  usual  pultaceous  material  and  hair,  I  observed  a 
mamma  projecting  from  the  cyst  wall.  It  was  as  large 
as  a  Tangerine  orange,  and  furnished  with  two  slender 
elongated  nipples,  which  were  attached  to  the  wall  of  the 
cyst  by  their  distal  extremities.  The  base  of  each  nipple 
was  surrounded  by  an  areola.  Each  nipple  was  per- 
forate, and  communicated  with  glandular  tissue  in  the 
midst  of  the  mamma.  The  glandular  portion  was  small 
in  amount,  and  embedded  in  rich  yellow  fat.     The  ducts 


6o  Diseases  of  the  Oi'aries. 

and  passages  were  filled  with  fluid  resembling  very  poor, 


Fig.  21. — Mammiferous  Dermoid.     Half  the  natural  size.     {Trans.  Path.  Soc.) 
The  gland  has  two  tube-like  nipples,  one  of  which  has  been  divided. 


but  viscid,  milk.     Under  the  microscope  this  fluid  had  all 

the  characters  of  milk,  and  contained  colostrum  globules. 

Structurally,  the  secreting  tissue  of  the  gland  differed 


Ma  MMiFER  o  US  D  i:r  mo  ids. 


6i 


from  a  normal  mamma  only  in  the  character  of  the 
epithelium,  which,  instead  of  being  cubical  in  shape,  was 
spheroidal,  and  several  rows  deep  (Fig.  21). 

Dr.  Desiderius  von  Velits  *  has  described  a  most 
perfect  example  of  an  ovarian  mamma  which  yielded 
milk  and  colostrum. 


Fig.  22.  — Histological  Characters  01  the  Ovarian  Mamma  described  by  Velits. 
a.  Pigmented  connective  tissue ;  b,  plain  muscle  fibre;  c,  d,  and  e,  gland- acini  and  ducts. 

Up  to  the  present  time  I  have  not  succeeded  in 
obtaining,  in  so  far  as  histological  details  go,  so  perfect  a 
specimen  as  that  described  by  Velits.  In  his  case  the 
glandular  elements  were  typical  of  the  normal  mamma 
(Fig.  22). 

Horn  and  nail. — Horns  resembling  those  which 
grow  from  sebaceous  cysts  are  occasionally  found  in 
ovarian  dermoids,  and  tissue  identical  with  nail  has  been 


'"'  Virchow's  Archiv,  Bd.  cvii.  s.  505. 


Fig.  23. — Ovarian  Dermoid.     {Travis.  Obstet.  Soc,  London.) 
The  lower  part  of  the  tumour  contained  teeth-germs  in  early  stages  of  development. 


Oi'ARiAX  Teeth.  63 

described   growing  from    the   extremity  of  a  finger-like 
skin-covered  projection  from  their  walls. 

Teetli. — A  large  proportion  of  ovarian  dermoids  con- 
tain feefh.  In  7uimber  they  vary  considerably ;  some- 
times two  or  three  are  found,  in  others  twenty,  and  as 
many  as  four  hundred  have  been  counted.  It  is  unusual 
to  find  more  than  twelve  teeth  in  a  cyst.  As  a  rule  they 
are  embedded  in  loose  bone  resembling  alveolus,  or  pro- 
ject from  a  flat  bony  plate  like  nails  driven  into  a  piece 
of  thin  wood. 

They  develop  on  the  same  plan  as  teeth  in  the 
normal  situation.  Their  mode  of  development  I  was 
able  to  study  under  unusually  favourable  conditions. 

The  tumour  represented  in  Fig.  23  is  shown  nearly 
natural  size.  It  consisted  of  two  parts  :  one  was  a  thin- 
walled  cyst  full  of  sebaceous  material,  and  lined  with 
pihferous  skin.  The  larger  portion  w^as  nearly  solid. 
When  sections  of  this  part,  removed  from  the  spot  marked 
H  in  the  figure,  were  prepared  for  the  microscope,  they 
presented  enamel  organs,  dentine  papillae,  hair,  glands, 
and  epithelial  pearls  in  early  stages  of  development. 
Epithelial  pearls  are  rounded  bodies  resembling  the 
boiled  lens  of  a  fish ;  they  are  occasionally  found  free  in 
dermoids.  They  are  composed  entirely  of  epithelial 
cells.     iySee  Plate  I.,  Frontispiece.) 

Teeth  are  not  scattered  irregularly  through  the  tumour 
unless  present  in  very  great  number,  but  are  collected 
together  in  one  or  more  groups.  They  vary  greatly  in 
shape  and  resemble  incisors,  canines,  and  supernumerary 
teeth  (Fig.  24). 

In  the  majority  of  cases  the  root  is  single  ;  when  the 
crown  is  simple  the  root  is  long ;  multicuspidate  teeth 
have  short  roots.  Ovarian  teeth  with  more  than  one 
root  are  very  rare. 

In  ovarian  teetli   enamel  and  dentine  are  invariably 


64 


Diseases  of  the  Oi'ARies. 


present ;  cementum  is  not  so  constant.  The  enamel  is 
lodged  upon  the  crown  in  lumps  or  hummocks,  with  deep 
ravines  extending  to  the  dentine.  The  fibres  of  the 
enamel  run  in  all  directions  (Fig.  25). 


Fig.  24.— Ovarian  Teeth  :    showing  Canines,   Bicuspldate,  and  Multicuspidate 

Teeth. 

C,  Geminated  tooth  ;  E,  caniniform  tooth  ;  C,  crown  showing  so-called  caries  : 
multicuspidate  crown. 

The  pulp  is  very  irregular  ;  some  ot  the  teeth,,  espe- 
cially those  resembling  incisors  and  canines,  may  lack  a 
central  chamber.  In  multicuspidate  teeth  the  pulp 
chamber  is  of  fair  size.  In  some  the  pulp  is  converted 
into  osteo-dentine ;  in  others  it  is  full  of  fat  globules. 

The  presence  of  nerves  in  the  pulps  of  ovarian  teeth 


Nerves  in  Dee  mows. 


65 


was  asserted  by  Salter,  and  tissue  resembling  nerve-fibrils 
maybe  detected  in  pulp 
suitably  prepared. 

The  existence  of 
nerves  in  ovarian  der- 
moids requires  further 
investigation  before  we 
can  be  sure  that  the 
fibrils  in  the  piilps  of 
the  teeth  are  really 
nerves.  My  own  obser- 
vations led  me  to  believe 
that  the  skin  of  der- 
moids is  sensitive,  and 
it  must,  therefore,  con- 
tain nerves,  but  their 
presence  and  the  exist- 
ence of  peripheral  end- 
organs  have  yet  to  be 
satisfactorily  demon- 
strated. 

The  clearest  example 
of  nerve  tissue  in  a 
dermoid  which  has  come 
under  my  own  notice 
was  in  a  specimen  re- 
moved by  Dr.  Bantock. 
The  patient  had  a  der- 
moid in  each  ovary. 
The  left  tumour  was 
multilocular,    and     one 

of  the  loculi  contained  what  appeared  to  be  a  peduncu- 
lated cystic  body  as  large  as  a  cherry.  On  incising  this, 
some  peculiar  diffluent  white  substance,  like  brain  matter, 
escaped.  The  walls  of  this  cyst  were  composed  of  tough 
F 


Fig.  25. — Microscopic  characters  of  a  Miil- 
ticuspidate  and  Biciispidate  Ovarian  Tooth. 

In  A  the  pulp  chamber  contains  osteo-dentine  ;  in 
li  the  pulp  chamber  is  exceedingly  small,  and 
occupied  with  osteo-dentine  ;  ceraentum  is 
absent  from  the  fan^s. 


66  Diseases  oe  the  Ovaries. 

fibrous  tissue,  like  dura  mater ;  the  interior  had  a  Hning 
of  highly  vascular  membrane,  like  pia  mater.  Attached 
to  this  were  fragments  of  tissue,  resembling  the  grey 
matter  of  the  spinal  cord,  presenting  large  ganglion  cells 
entangled  in  neuroglia. 


Fig.   26. — Ovarian  Dermoid. 

The  loculus,  C,  contains  a  small  cyst  filled  with  tissue  microscopically  identical  with  brain 

matter.     F.t,  Fallopian  tube  ;//;«/',  fimbrire. 


Nerve  matter  has  been  detected  in  ovarian  dermoids 
by  Gray,*  and  recently  by  Neumann.!  The  nerve  tissue 
in  Dr.  Bantock's  specimen  existed  in  circumstances 
identical  with  those  described  by  Gray  and  Neumann. 

It  is  a  fact  of  great  interest  that  ovaries  even  when 
occupied  by  fairly  large  dermoids  sometimes  successfully 

*  Med.  Chir.  Tra?isacfions,  vol.  xx.xvi,  p.  434  ;   1853. 
t  Virghow's  Archiv,  188^, 


Dermoids  and  Pregnancy,  67 

discharge  their  functions.  In  1885  Mr.  Thornton  re- 
ported to  the  Obstetrical  Society  details  of  a  case 
in  which  he  performed  double  ovariotomy  during 
pregnancy.  The  patient  was  twenty-two  years  of  age. 
Both  tumours  were  dermoid.  One  had  a  twisted  pedicle, 
the  other  was  impacted  in  the  pelvis.  The  left  one  had 
a  well-developed  corpus  luteum  on  its  outer  surface. 

In  1890  Dr.  Bantock"^  performed  double  ovariotomy 
on  a  lady  in  the  third  month  of  pregnancy.  Both 
tumours  were  dermoids.  They  were  submitted  to  me 
for  examination.  Even  after  microscopic  investigation  I 
was  unable  to  detect,  normal  ovarian  tissue.  The 
tumours  from  Dr.  Bantock's  patient  are  represented  in 
Figs.  26  and  27. 

Cullingworth  t  has  recorded  an  instance  in  which 
both  ovaries  were  converted  into  dermoids  in  a  woman 
thirty-nine  years  of  age.  She  had  had  twelve  children  and 
three  miscarriages — the  last,  three  months  before  opera- 
tion j  and  he  remarks  :  ^'  One  would  find  it  difficult  to 
define  the  precise  amount  of  ovarian  disease  that  is 
necessary  to  render  a  woman  sterile." 

The  dermoids  in  this  case  have  been  carefully 
described  by  Shattock.+ 

Dermoids  occur  at  all  periods  of  life.  They  have 
been  recorded  in  the  ovary  at  birth  and  in  patients  up- 
wards of  eighty  years  of  age.  I  have  devoted  much 
labour  to  the  examination  of  fcetal  ovaries,  but  have 
never  succeeded  in  detecting  an  ovarian  dermoid  at  birth, 
neither  can  I  refer  the  reader  to  a  trustworthy  case.  In 
chapter  viii.  references  are  furnished  of  many  ex- 
amples removed  from  children  under  fifteen  years  of 
age. 

*  Journal  of  the  Bj'it.  Gyn,  Sac,  January,  1890. 
t  St.  Thomases  Hospital  Reports,  vol.  xvii.  ;    1889.- 
X   Trans.  Path.  Soc,  London,  vol.  xxxix.  p.  442. 

F    2 


68 


Diseases  of  the  Ovaries. 


In  1890  Mr.  John  Ewens,  of  Clifton,  was  good  enough 
to  send   nic,   for  examination,  an   ovarian   dermoid,   as 


Fig.  27. — Ovarian  Dermoid  from  a  pregnant  Woman.     (The  tumour  of  the  left 

side  is  represented  in  Fig.  26.) 

F.t.,    Fallopian  tube  ;  fiynb,  fimbria  ;  T,  teeth. 

large  as  a  cricket-ball,  he  had  successfully  removed  from  a 
girl  of  seven  years.  Besides  many  teeth,  six  of  which  were 
fully  erupted,  it  contained  a  lock  of  hair  75  cm.  in  length. 


Secoxdarv  Dermoids.  69 

Potter  *  has  recorded  a  case  in  which  a  woman  eighty- 
three  years  of  age  died  after  a  severe  burn.  She  had  an 
ovarian  dermoid  which  had  made  one  complete  rotation. 
The  tumour,  so  far  as  was  known,  had  never  caused  her 
any  inconvenience. 

Among  exceptional  cases  of  ovarian  dermoids  the 
following  deserve  mention  : — 

Matthews  Duncanf  mentions  a  case  which  came  under 
his  care,  in  which  Mr.  Langton  removed  "  both  ovaries, 
both  being  dermoid  cysts.  A  third  cyst,  the  size  of  an 
egg,  having  hair  growing  from  its  inner  surface,  was  re- 
moved from  between  the  layers  of  the  mesentery ;  it  had 
no  connection  with  either  ovary.  In  both  of  these  cases 
there  was  good  recovery,  so  that  the  precision  attainable 
by  autopsy  was  not  obtained."  Ovarian  dermoids 
associated  with  detached  cysts  in  this  way  are  exces- 
sively rare.  The  most  remarkable  case  is  described  by 
Moore.  I 

A  married  woman,  twenty-eight  years  of  age,  had 
suffered  from  an  abdominal  tumour  for  ten  years.  It  sup- 
purated, and  the  pus  escaped  through  a  fistulous  opening 
at  the  umbilicus.  She  died  a  iQ\w  days  after  her  admis- 
sion into  the  ]\Iiddlesex  Hospital.  At  the  post  mortem 
examination  a  huge  ovarian  dermoid,  universally  adherent, 
was  found,  containing  large  quantities  of  hair  and  a  great 
number  of  teeth. 

"  Among  the  peritoneal  adhesions  were  many  small 
cysts,  some  of  which  were  attached  by  slender  pedicles 
to  the  main  cyst ;  whilst  others  were  entirely  unconnected 
with  it,  l)ut,  hke  it,  contained  soft,  cheesy,  yellow  epithe- 
lium, mixed  with  hairs.  One  was  in  the  great  omentum. 
Two,  which  were  in,  or  near,  the  right  broad  ligament,  and 

*   Trans.  Obstet.  Sac,  London,  vol.  xii.  p.  246. 

t  Ibid.,  vol.  xxiv.  p.  318. 

X  Trans.  Path.  Soc,  London,  vol.  xviii.  p.  190. 


70  Diseases  of  the  Ovaries. 

of  the  sizes  of  a  nutmeg  and  a  walnut,  had  ossified,  or 
chalky,  walls.  Many  small  ones  were  in  situations  where 
they  might  have  been  supposed  to  be  diseased  absorbent 

glands,  as  in  the  pelvis  or  mesentery The 

largest  of  the  loose  cysts  lay  among  the  adhesions  of  the 
small  intestines.  It  was  completely  separated  by  the 
bowels  from  the  principal  cyst,  and  it  was  rather  larger 
and  longer  than  a  hen's  egg." 

Such  a  case  raises  the  important  question  of  metas- 
tasis in  relation  to  ovarian  dermoids.  In  the  description 
of  papillomatous  cysts  it  will  be  pointed  out  that  when 
they  rupture  epithelial  elements  engraft  themselves  upon 
the  peritoneum,  and  form  warts.  There  is  good  reason  to 
believe  that  similar  transplantation  occurs  with  dermoids. 

Kolaczek*  reported  a  case  in  which  Martini  removed 
from  a  single  woman,  forty  years  of  age,  an  ordinary 
ovarian  dermoid  as  large  as  a  man's  head.  Its  surface 
was  perfectly  smooth.  After  the  escape  of  some  ascitic 
fluid  the  peritoneum  was  seen  to  be  dotted  with  small 
yellow  knots ;  many  of  them  were  furnished  with  a  small 
tuft  of  light  hair,  which  projected  into  the  peritoneal 
cavity.     This  case  is  unique. 

Dermoids  are  usually  regarded  as  innocent  tumours, 
but  a  collective  investigation  of  this  subject  raises  consider- 
able doubt,  especially  when  they  occur  before  puberty. 
The  evidence  on  this  matter  is  set  forth  in  chapter  viii. 

x\s  far  as  possible,  theoretical  points  have  been  ex- 
cluded in  this  chapter.  Those  who  feel  inclined  to  study 
the  subject  more  fully  will  find  further  information  in 
my  little  monograph  on  Dermoids.  A  more  recent  re- 
search on  the  structure  and  development  of  ovarian  teeth 
and  the  formation  of  epithelial  pearls  I  communicated  to 
the  Odontological  Society  of  Great  Britain  in  1890.  | 

*  Virchow's  Archiv,  Bd.  75,  s.  399. 

+    Trans.  Odonto.  Soc,  vol.  xxii.  p.  156. 


7^ 


CHAPTER    VII. 

SOLID    TUMOURS    OF    THE    OVARY. 

Solid  tumours  of  the  ovary  are  far  less  common  than 
the  cystic  variety  and  form  about  five  per  cent,  of  the 
cases  submitted  to  operation.  They  form  four  groups  : — 
Fibromata,  Myomata,  Sarcomata,  and  Carcinomata.  The 
occurrence  of  the  first  three  forms  is  no  matter  for  surprise, 
as  the  ovary  contains  connective  tissue  in  abundance, 
and  a  small  amount  of  unstriped  muscle  fibre. 

Fibromata. — Fibrous  tumours  of  the  ovary  are  very 
rare.  Doran,*  who  has  written  an  admirable  monograph 
on  this  subject,  states  that  he  has  examined  microscopically 
three  solid  ovarian  tumours,  which  appeared  as  though 
entirely  made  up  of  white  fibrous  tissue.  The  minute 
structure  of  such  tumours  consists  of  characteristic  wavy 
bundles  of  fibrous  tissue  in  most  parts  of  the  sections, 
packed  closely  together.  Intermixed  with  these  are  small 
round  cells,  and  among  the  fibrous  tissue,  lying  in  the  long 
axis  of  the  fibres  composing  the  bundles,  a  few  small 
spindle  cells  were  detected.  Thus  the  histology  of  ovarian 
fibromata  is  identical  with  fibrous  tumours  occurring  in 
other  situations. 

Ovarian  fibromata  sometimes  attain  a  large  size.  Dr. 
John  Williams t  has  described  a  specimen  which  weighed 
7  lbs.  7  ozs.  A  large  cyst  was  connected  with  the  tu- 
mour ;  on  its  thin  tough  walls  there  were  a   few  papillje. 

*    Trans.     Obstet.    Soc,    vol.    xxix.     p.    410;     "On     Myoma    and 
Fibro-myoma  of  the  Uterus  and  Allied  Tumours  of  the  Ovary." 
f   Trans.  Obstet.  Soc,  London,  vol.  xxx.  p.  247  and  p.  513. 


72  Diseases  of  the  Ovaries. 

The  pedicle  was  twisted.  A  committee  of  the  Society 
reported  that  the  tumour  was  an  ahiiost  pure  fibroma. 

Doran  briefly  mentions,  in  the  paper  to  which  refer- 
ence has  been  made,  the  following  facts  relating  to  a 
large  fibroma  of  the  ovary  removed  by  Mr.  Thornton,  in 
1884,  from  a  woman  twenty  years  of  age.  She  married 
at  the  age  of  fifteen,  but  had  never  borne  children. 
Previous  to  the  operation  sexual  desire  appears  to  have 
been  absent.  After  recovery  the  instinct  rapidly  devel- 
oped :  the  patient  left  her  husband,  and  bore  a  child  to 
another  man.  Ultimately  she  returned  to  her  home,  and 
in  1888  was  in  good  health. 

The  pedicle  was  long  and  narrow,  and  the  relation  of 
the  tube  and  broad  ligament  proved  clearly  that  the 
tumour  was  ovarian.  The  uterus  was  healthy,  the  oppo- 
site ovary  small  and  infantile. 

Myoinata. — Tumours  of  the  ovary  composed  mainly 
of  unstriped  muscle  fibre,  or  a  mixture  of  muscle  and 
fibrous-tissue — fibro-myomata — are  more  frequent  than 
the  pure  fibromata,  but  they  are  not  by  any  means 
common. 

Unstriped  muscle  tissue  occurs  in  the  ovary  in  the 
form  of  longitudinal  bands,  which  are  prolonged  from  the 
ovarian  ligament,  and  penetrate  the  tissues  of  the  paro- 
ophoron. 

In  determining  the  nature  of  a  solid  ovarian  tumour 
we  encounter  the  well-known  histological  difticulty  of 
deciding  between  a  myoma  and  a  spindle-cell  sarcoma. 

A  few  years  ago  Mr.  J.  Taylor,  of  Birmingham,  sent 
me  an  enlarged  ovary,  which  he  removed  from  a  young 
woman.  Before  removal  there  had  ]:)een  much  difference 
of  opinion  as  to  the  nature  of  the  enlargement:  one 
surgeon  expressed  the  oi)inion  that  the  condition  was  due 
to  inflammation.  On  cutting  through  the  ovary  its  centre 
was    found    occupied    by    tissue,    resembling   in    colour 


Ovarian  AIvoi\jata.  73 

old  blood-clot,  the  ovarian  tissue  being  expanded 
over  it  like  a  capsule.  The  relation  of  the  parts  is  shown 
in  Plate  II.  Under  the  microscope  this  tissue  was  found 
to  be  composed  almost  entirely  of  large  spindle-cells. 

At  that  time  my  experience  of  these  tumours  was  not 
extensive,  and  I  felt  great  difficulty  in  deciding  whether 
this  tumour  should  be  regarded  as  a  sarcoma  or  myoma. 


Fig.    28. — Ovarian  Fibro-myoma.     (Museum  of  the  Hospital  for  Women,  Soho. 

F,  Fallopian  tube. 

I  inclined  to  the  opinion  that  it  was  a  sarcoma,  and  sug- 
gested that  the  subsequent  history  of  the  case  would 
settle  the  true  nature  of  the  tumour.  Several  years  have 
elapsed,  and  there  has  been  no  evidence  of  recurrence. 

This  is  the  earliest  stage  in  which  I  have  had  oppor- 
tunity of  examining  a  tumour  of  this  type.  Ovarian 
myomata  sometimes  attain  large  dimensions. 

The  museum  of  the  Hospital  for  Women,  Soho, 
contains  a  specimen  of  ovarian  fibro-myoma  removed  by 
Mr.  Reeves  (Fig.   28).     It  weighs   about  3  lbs.,  and,  on 


74  Diseases  of  the  Ovaries. 

section,  presents  the  usual  whorled  appearance  of  a  uterine 
fibro-myoma. 

The  museum  of  the  Royal  College  of  Surgeons 
contains  a  specimen  weighing  15  lbs.  2  ozs.,  removed  by 
Sir  Spencer  Wells  from  a  single  woman,  sixty-eight  years 
of  age.  She  had  noticed  the  tumour  eight  years.  It  had 
a  good  pedicle ;  the  Fallopian  tube  and  broad  ligament 
were  free  from  disease.  Doran,  who  has  carefully  exam- 
ined and  figured  this  tumour,  found  it  to  be  a  myoma. 

Bagot*  has  recorded  a  case  of  fibro-myoma  of  the 
ovary  from  a  woman  aged  forty-four  years.  The  tumour 
was  small. 

Ovarian  myomata  and  fibro-myomata  resemble,  in 
their  minute  structure,  similar  tumours  of  the  uterus  : 
they  may  consist  of  large  fusiform  cells  with  little  fibrous 
tissue,  or  the  fibrous  tissue  may  predominate.  There  is 
some  evidence  to  lead  us  to  believe  that  the  tissue  of 
which  they  are  composed  may  undergo  myxomatous 
change,  and  form  spurious  cysts. 

Sarcomata. — Ovarian  tumours  belonging  to  this 
group  deserve  more  careful  study  than  they  have  hitherto 
received.  They  differ  from  sarcomata  generally  in  the 
fact  that  frequently  both  ovaries  are  affected  primarily  in 
the  same  patient,  and  in  the  circumstance  that  masses 
of  tissue,  which  under  the  microscope  are  indistinguish- 
able from  sarcomatous  tissue,  occur  not  infrequently  in 
association  with  ovarian  dermoids.  It  has  been  stated 
that  malignant  deposits  have  occurred  in  the  pelvis 
after  removal  of  dermoids  containing  such  sarcoma-like 
tissue. 

Ovarian  sarcomata  may  belong  to  the  spindle-celled 
or  round-celled  varieties.  Spindle-celled  sarcoma  seems 
the  more  frequent. 

*   Trans.  Royal  Acad,  of  Med.,  Ireland,  1890^  vol.  viii.  p.  322. 


TUBE 


PAROVARIUM 


TUMOUR 


Plate  II.— Myoma  of  the  Ovary.     Natural  size. 


OVARIAN  Sarcomata.  75 

It  is  important  to  remember  that  the  majority  of 
solid  ovarian  tumours  which  are  classed  in  museums  as 
fibromata  of  the  ovaries  are  in  nearly  all  cases  examples 
of  ovarian  sarcomata, 

A  striking  illustration  of  this  is  a  case  described 
by  Cullingworth.  *  A .  woman,  aged  thirty-six  years, 
came  under  observation  complaining  of  slight  uterine 
haemorrhage,  which  lasted  continuously  for  three 
months.  Two  hard,  solid,  nodulated  tumours  were  dis- 
covered in  the  pelvis.  The  patient  had  been  aware  of 
the  existence  of  an  abdominal  swelling  for  five  years. 
Three  months  after  seeking  advice  she  began  to  lose 
flesh,  and  fluid  accumulated  in  the  abdomen.  A  month 
later  effusion  into  the  left  pleura  was  recognised,  and  she 
died  somewhat  suddenly  a  few  weeks  afterwards. 

At  the  post  mortem  examination  two  solid  ovarian 
tumours  were  found.  They  were  firm  and  nodulated, 
whitish  in  colour,  with  a  smooth,  glistening  surface.  The 
specimens  were  regarded  by  Dr.  Dreschfeld,  who  ex- 
amined them  microscopically,  as  fibromata.  When  the 
tumours  were  exhibited  at  the  Obstetrical  Society  they 
were  re-examined  by  a  committee,  and  the  specimens 
were  subsequently  reported  to  be  mixed- celled  sar- 
comata. 

The  pathology  of  solid  ovarian  tumours  is  extremely 
unsatisfactory,  and  requires  most  careful  consideration. 
It  is  not  a  subject  that  can  be  settled  by  simply  collect- 
ing reports  of  cases  from  periodical  literature,  or  even 
by  the  examination  of  museum  specimens,  unless  such 
possess  a  careful  history. 

The  absence  of  accurate  knowledge  is  in  a  large 
measure  due  to  the  infrequency  of  solid,  in  comparison 
with  the  frequency  of  cystic  tumours  of  the  ovaries. 

*   Trans.  Ohstet.  Soc,  London,  vol.  xxi.  p.  276. 


76  Diseases  of  the  Ovaries. 

Ovarian  sarcomata  differ  from  sarcomata  in  general 
in  several  important  particulars.  In  the  first  place,  both 
ovaries  are  frequently  affected  primarily.  This  is  con- 
trary to  the  rule  of  malignant  tumours.  Occasionally 
we  meet  with  cases  in  which  there  is  a  general  outbreak 
of  sarcoma,  nodules  appearing  in  various  parts  of  the 
body  almost  simultaneously.  Such  instances  are  rare. 
Primary  sarcoma  appearing  simultaneously  in  two  long 
bones  of  an  individual,  or  both  testicles,  is  almost 
unknown ;  yet  in  the  ovaries  it  appears  to  be  the 
rule.  The  form  of  sarcoma  which  can  be  compared 
with  ovarian  sarcoma  in  this  respect  is  glioma  of  the 
retina. 

Messrs.  Lawford  and  Collins,*  in  their  careful  analysis 
of  six-ty  cases  of  glioma  retinae,  ascertained  that  in 
twelve  cases  the  disease  attacked  both  eyes  simultaneously, 
or  with  very  short  intervals  ',  and  Hirschberg,  in  a  similar 
analysis  of  sixty  cases,  found  both  eyes  affected  in 
fourteen. 

Judging  from  the  imperfect  records  of  ovarian 
sarcoma,  I  have  come  to  the  conclusion  that  both 
ovaries  are  affected  in  the  proportion  of  about  twenty  per 
cent,  of  the  cases. 

Sarcoma  of  the  ovary  grows  very  rapidly,  and  some- 
times attains  in  a  few  months  a  large  size.  Dr.  Carter  f 
described  a  specimen  which  in  a  period  of  about  six 
months  grew  so  large  that  on  removal  it  w^eighed  more 
than  I  o  lbs. 

The  subject  of  ovarian  sarcomata  in  children  is  con- 
sidered in  the  next  chapter. 

Carciiioinata. — In  the  majority  of  instances  cancer 
of  the  ovary  is  secondary.     Our  knowledge  of  primary 


*  Royal  London  Ophth.  Hospital  Reports,  vol.  xiii.  p.  2, 
t   Tra?is.  Obstct.  Soc,  London,  vol.  xxix.  p.  190. 


Ofartan  Cancer.  77 

cancer  of  this  organ  is  very  limited,  and,  except  in  a  few 
instances,  extremely  unsatisfactory. 

The  term  cancer  must  be  used  in  a  definite  sense, 
and  reserved  for  mahgnant  adenomata.  An  adenoma  is 
a  neoplasm  conforming  in  histological  details  to  the  type 
of  a  secreting  gland.  The  less  perfectly  an  adenoma 
mimics  a  gland,  the  more  likely  is  it  to  exhibit  malignant 
properties,  and  come  under  the  denomination  "  Cancer." 
Adenomata  and  carcinomata  have  a  common  feature 
in  the  possession  of  epithelium  arranged  in  a  definite 
manner.  The  curious  expression  so  frequently  used  by 
some  writers  that  cancer  or  a  sarcoma  is  a  reversion  to 
the  fcetal  type  is,  to  my  mind,  meaningless,  except 
that  it  indicates  either  a  love  for  the  mysterious  or 
else  ignorance. 

There  is  good  anatomical  reason  to  lead  us  to  believe 
that  primary  cancer  may  arise  in  the  ovary.  Adenomata 
of  most  perfect  form,  and  furnished  with  highly-developed 
epithelium,  arise  in  the  ovary,  and  experience  proves  that 
wherever  adenomata  are  found  cancer  also  occurs.  To 
discuss  the  source  of  the  epithelium  is  so  purely 
morphological  as  to  be  beyond  the  scope  of  this  work. 

Shattock"^  has  recorded  a  case  of  colufiinar-celled 
carcinoma  of  the  ovary.  The  ovary  was  converted  into 
a  great  lobulated  oval  tumour,  eleven  inches  by  five  in  its 
chief  diameters.  Histologically,  it  consisted  of  tortuous 
loculated  channels,  of  various  forms,  according  to  the 
direction  of  their  section,  lined  with  remarkably  tall, 
slender,  and  very  closely-compressed  columnar  epithe- 
lium, disposed  in  a  single  layer,  and  everywhere  bounding 
a  lumen.  "  The  stroma  between  the  spaces  is  of  a  delicate 
richly-celled  connective  tissue,  and  is  about  in  the  same 
proportion  as  the    tubular  elements.     The  contents   of 

*    Trans.  Path.  Soc,  vol.  xl.  p.  208. 


78  Z)  IS  EASES    OF    THE    Ov  ARIES. 

the  spaces  are  sharply  demarcated  from  the  cells,  and 
consist  in  many  of  an  unstained  glassy,  minutely  fissured 
substance,  presenting  very  clear  traces  of  concentric 
lamination." 

Doran*  refers  to  an  ovarian  tumour  removed  by 
Thornton  from  a  girl  fifteen  years  of  age,  which  he 
regards  as  an  undoubted  example  of  cancer.  On  micro- 
scopical examination  it  was  found  to  consist  of  cells 
closely  packed  in  alveoli  formed  by  dense  connective 
tissue  (Fig.  35). 

The  youth  of  this  patient  introduces  an  element  of 
doubt  as  to  whether  we  have  to  deal  with  cancer  in  this 
case.  The  peculiar  histological  characters  should  be 
compared  with  those  presented  by  solid  ovarian  tumours 
occurring  in  children  at  birth.  These  tumours  present 
characters  which  isolate  them  from  cancers  in  general,  as 
well  as  from  the  more  usual  forms  of  sarcomata,  and 
which  are  discussed  in  the  ensuing  chapter. 

In  Shattock's  case  the  clinical  course  was  very 
rapid.  The  tumour  had  only  been  noticed  six  months 
before  the  patient  came  under  observation.  An  attempt 
was  made  by  Mr.  Pitts  to  remove  it,  but  the  patient's 
condition  became  so  critical  that  the  operation  was  aban- 
doned. The  woman  died  forty-eight  hours  after  the 
operation. 

Secondary  cancer. — It  is  a  curious  rule  that  organs 
which  are  frequently  the  seat  of  primary  cancer  are 
rarely  the  seat  of  secondary  deposits,  and  vice  versa.  To 
this  the  ovaries  are  not  exceptions,  and,  what  is  some- 
what remarkable,  secondary  cancer  affects  both  organs  in 
more  than  half  the  cases. 

The  relative  frequency  with  which  the  ovaries  are 
affected  with  secondary  deposits  of  cancer  has  not  been 

*   Tumours  of  the  Ovary,  p.  103. 


Second ARv  Ovarian  Cancer. 


79 


investigated  on  any  very  extensive  basis.  Nevertheless, 
some  attention  has  been  given  to  this  question,  and  it 
would  appear  that  mammary  cancer  and  melanotic 
tumours  give  rise  to  secondary  deposit  in  the  ovaries. 

Dr.  Sidney  Coupland*  reported  to  the  Pathological 
Society  a  case  of  mammary  cancer  which  occurred  in  the 


Fig.  29. — Section  of  an  Ovary,  with  Secondary-  Deposits  of  Melanotic 
Cancer.     Natural  size. 


right  breast  of  a  woman  twenty-four  years  of  age.  The 
breast  was  removed  and  she  remained  well  for  five  months, 
then  two  recurrent  knots  appeared  in  the  scar.  These  were 
removed.  A  few  weeks  later  "  a  sudden  and  rapid 
evolution  of  secondary  knots  took  place  " ;  the  left  breast 
and  all  the  soft  tissues  on  the  front  and  sides  of  the  chest 
became  infiltrated  and  converted  into  an  inflexible  and 
brawny  cuirass,  and  in  three  weeks  she  died.     Mr.  J.  W. 


*   T?'a?is,  Path.  Soc. ,  vol.  xxviii.  p.  2^9. 


8o 


Diseases  of  the  Ovaries. 


Hulke,  who  had  charge  of  the  patient,  informed  -Dr. 
Coiipland  "  that  in  all  his  experience  he  had  never  seen 
so  rapid  a  recurrence  and  extensive  diffusion  of  cancer 
take  place  in  so  short  a  time." 


Fig.  30. — Cancer  deposits  in  Ovary  ;  secondary  to  Cancer  of  Breast.     Both 
ovaries  were  affected.     Nearly  natural  size. 


At  the  post  mo7'tein  examination  the  abdominal  organs 
and  peritoneum  were  free  from  secondary  growth,  except 
the  ovaries.  The  "  cancer  had  attacked  the  ovaries 
symmetrically,  and  so  symmetrically  that  in  size  and 
appearance  these  organs  differed  hardly  at  all  from  each 
other.     Each  was  enlarged  to  the  size  of  a  chestnut,  was 


Secondary  Ovarian  Cancer.  8i 

adherent  to  its  Fallopian  tube,  and  presented  slight 
lobulation.  On  section  the  ovary  was  soft,  of  a  pure 
white  colour  throughout,  presenting  no  traces  of  normal 
structure.  Microscopically  it  presented  the  characters  of 
cancer,  the  stroma  being  reduced  to  a  minimum." 

The  careful  description  of  this  remarkable  case  is 
rendered  more  valuable  by  the  fact  that  a  table  is 
appended,  compiled  from  annual  reports  of  the  Surgical 
Registrars  of  the  Middlesex  Hospital,  June,  1867,  to  1874 
inclusive,  showing  the  relative  frequency  of  secondary 
implication  of  viscera  in  mammary  cancer,  as  ascertained 
hy post  inortein  examination. 

The  total  number  of  cases  was  89 ;  the  ovaries  w^ere 
attacked  five  times.  In  three  cases  both  ovaries  were 
the  seat  of  secondary  deposits,  and  in  two,  one  ovary 
only  was  implicated. 

Secondary  deposits  of  cancer  in  the  ovary  are  more 
frequent  than  even  Dr.  Coupland's  interesting  paper 
indicates.  During  the  years  1887,  1888  and  1889  there 
w^ere  fifty-two  inspections  of  patients  dying  from  cancer 
of  the  uterus,  and  twenty-nine  from  cancer  of  the  breast. 
The  frequency  wnth  which  secondary  deposits  were  found 
in  the  ovaries  is  shown  in  the  subjoined  table :— 


UTERUS. 

OVARIES. 

52  cases. 

Deposits  in  both  glands, 

3  cases. 

Deposits  in  one  gland, 

3  cases. 

BREAST. 

29  cases. 

Deposits  in  both  glands, 

3  cases. 

I  intentionally  selected   those    three  years    because 

during   that   period  especial  attention  was  devoted,  by 

Mr.    L.    Hudson  who  made    the    examinations,  to    the 

diseases  of  the  internal  generative  organs  of  the  female. 

G 


82  Diseases  of  the  Ovaries. 

Of  course  no  case  is  included  in   which  the  ovary  was 
involved  by  extension  of  uterine  cancer. 

Many  cases  of  secondary  nodules  of  melanotic 
tumours  have  been  observed  in  the  ovary.  This  is  due 
to  two  causes  :  secondary  nodules  in  this  disease  are  so 
widely  disseminated,  and  the  colour  betrays  them  to  the 
eye  of  even  the  least  experienced  pathological  anatomist. 
It  is  quite  possible  that  in  some  cases  described  as  primary 
sarcoma  or  carcinoma  of  the  ovary,  the  growth  in  the 
ovary  was  really  secondary  to  cancer  of  some  other  organ, 
especially  in  those  cases  where  rapid  spread  of  the  disease 
followed  ovariotomy. 

•  Cancer  of  the  ovary  secondary  to  cancer  of  the  breast 
or  uterus  produces  a  characteristic  lobulation  of  the 
organ,  whereas  secondary  melanotic  deposits  are  rarely 
large  enough  to  affect  its  shape.  Compare  in  this  respect 
Figs.  29  and  30. 


83 


CHAPTER  Vlll. 

OVARIAN    TUMOURS    IN    INFANCY    AND    CHILDHOOD. 

Tumours  of  the  ovary  occur  in  foetal  and  infant  life. 
In  the  foetus  they  are  not  infrequent.  The  museums  of 
the  Royal  College  of  Surgeons,  University  College,  and 
St.  Thomas's  Hospital  contain  several  specimens.     Cysts 


Fig.  31.— Uterus  and  Ovaries  of  a  Child  two  months  old.     Natural  size. 
Each  ovary  is  occupied  by  a  cj'st,  that  in  the  right  ovary  has  a  secondary  loculus. 

of  the  oophoron  in  newly-born  children  have  been  figured 
and  described  by  Winckel,*  Cullingworth,t  and  others. 
I  have  examined  microscopically  five  specimens  which 
have  come  under  my  notice  in  foetuses.  No  one  who 
has  systematically  dissected  stillborn  children  can  have 
failed  to  observe  them. 

*  Lehrbuch  der  Fnuienkrankheiten,  1886. 

f  Obstetrical  Jounml  of  Great  Britain,  vol.  ii    p.  401. 

G    2 


84 


Diseases  of  the  Ovaries. 


Congenital  ovarian  cysts  may  be  unilocular  or  multi- 
locular,  unilateral  or  bilateral.  A  typical  example 
occupied  the  left  ovary  of  the  specimen  sketched  in 
Fig.  31.  That  in  the  right  ovary  is  somewhat  exceptional 
in  that  it  contains  a  secondary  loculus. 


Fig.  32.— Multilccular  Ovarian  Cyst  from  a  Foetus  born  at  full  time.      One 
and  a  halt  the  size  of  nature. 


An  example  of  a  multilocular  congenital  cystic  ovary 
is  represented  in  Fig.  32.  It  is  quite  possible  that  such 
cysts  develop  into  large  tumours.  I  have  collected  a 
number  of  cases  of  large  cystic  ovaries  that  have  been 
observed  in  girls  between  the  first  and  fifteenth  years  of 
life. 

The  largest  ovarian  tumour  in  a  foetus  on  record  is 
a  case  reported  by  Doran.'^  A  foetus  of  the  seventh 
month  was  born  with    its  abdomen  distended  and  the 

"^   l^ram.  Path.  !Soc.,  vol.  xl.  p.  200. 


Oi'ARiAN  Tumours  in  Fcetuses.  •85 

subcutaneous  veins  prominent.  It  survived  the  birth 
only  two  minutes.  On  opening  the  abdomen,  ascitic 
fluid  escaped,  and  an  ovarian  tumour  was  discovered 
on  each  side.  The  larger  tumour  is  shown  a  little 
reduced  in  size  in  Fig.  33.  "  When  fresh,  it  was  of  a 
bright  pink  colour,  faintly  tinged  with  lilac."  The  sur- 
face exhibited  numerous  minute  elevations,  as  though 
produced  by  cysts.  There  were  no  adhesions.   The  tumour 

ruBE 


Fig.  33. — Tumour  of  the  Ovary  from  a  seven  months'  Foetus.      A  little  less  than 
natural  size.     (After  Doran.) 

consisted  of  a  thin  shell  of  sohd  material,  enclosing  a  large 
central  cavity  containing  clear  fluid.  The  tumour  of  the 
left  ovary  was  slightly  smaller  than  its  fellow.  Sections 
of  the  tumour  when  viewed  with  the  naked  eye  appeared 
as  a  wide-meshed  net-work  with  trabecular,  the  spaces 
being  filled  with  semi-transparent  material.  Under  the 
microscope  the  trabeculge  appeared  to  consist  of  a  multi- 
tude of  small  round  cells  in  a  homogeneous  matrix. 
Among  this  tissue  ovarian  follicles  were  recognised. 

After  a  careful  and  detailed  description  of  the  his- 
tology of  the  specimen,  Doran  comes  to  the  conclusion 


86 


Diseases  of  the  Ovaries. 


that  the  enlargement  of  the  ovary  was  due  "to  hyper- 
plasia of  the  entire  embryonic  tissue  of  the  oophoron." 
It  is  fortunate  that  so  rare  a  specimen  came  into  the 
hands  of  such  a  competent  observer.  The  microscopical 
characters  of  sections  prepared  from  this  ovary  are 
depicted  in  Fig.  34;  and  it  is  remarkable  to  notice,  as 


/--i 


Fig.  34. — Histological    Characters   of  the   Tumour  of  the   Ovary   of  a  seven 
months'  Foetus.     (After  Doran.) 

c.  Wall  of  the  cavity  ;  f,  ovarian  follicle  with  ovum. 

Doran  also  observes,  that  the  cells  which  form  so  con- 
spicuous a  part  in  its  structure  are  identical  in  appearance 
with  those  which  are  so  abundant  in  the  ovarian  stroma 
early  in  foetal  life.  The  histology  of  this  remarkable 
ovary  is  interesting  in  its  bearing  on  the  solid  ovarian 
tumours  occurring  in  infants  and  girls  under  puberty. 
The  following  table  contains  a  list  of  sixty  cases  of 
ovarian  cysts  and  tumours  occurring  before  the  fifteenth 
year,  which  I  have  collected  and  briefly  analysed. 


Ol'ARlAN    TUMOVRS    IN    CHILDHOOD 


87 


Table  of  Cases  of  OornoRiTic   Tumours    in    Infants  and 
Girls    under    Fifteen. 


REI'ORTER. 

Age. 
r  yr,  and 

Resilt. 

Nature  of 

TU.MOUR. 

Reterence. 

Kiister  (for 

Ovariotomy : 

Dermoid    ... 

Deutsche   Med.    Woch., 

Roemer) 

8  mths. 

recovery. 

Dec.  26th,  1883. 

J.  F.  Hooks 

2  yrs.  and 

0\'ariotomy  : 

Dermoid  ;  very  ad- 

A7n. Joi<r.  Obstet.^   vol. 

6  mths 

death. 

herent. 

.xi.\-.  p.  1022. 

Kidd      (for 

2  yrs.  and 

Ovariotomy : 

Dermoid    

Obstet.  Jour.  Gt.   Brit. , 

Neville) 

II  mths. 

death. 

1880,  vol.  viii.  p.  241. 

Alcock 

3  3'ears  ... 

Ovariotomy : 
death. 

]\Iultilocular  cyst... 

LaMcet,   1871,   vol.   ii. 
p.  850. 

Schwartz ... 

4  years  . . . 

Ovariotomy' : 
recovery. 

Adenoma   ... 

Arc/i.    fur    Gyn.,    vol. 
xiii.  p.  475 

Thomas    ... 

3  yrs.  and 

No  operation 

Tumour        noticed 

Ai}t.  Joiir.  Obstet.,  Jan. 

5   mths. 

death. 

one    month  after 
birth  :    described 
as    an     ordinary 
ovarian  cyst. 

1880,       vol.     xiii.      p. 
118. 

Thornton... 

4  years  . . . 

Cyst  opened, 

Suppurating      der- 

Med.-Chir. Trans.,  vol. 

stitched  to 

moid. 

Ixx.  p.  75. 

abdominal 

wound  and 

drained  : 

recovery-. 

Boldt 

4  years... 

Incision  and 

Suppurating     ova- 

Proc.   Path.   Soc,  Ntiu 

drainage. 

rian  cyst. 

York,  1888,  p.  63. 

Mears    (for 

6  yrs.  an' 

Ovariotomy : 

Dermoid 

Phil.  Med.  Times,  Nov. 

Barker). 

8  mths 

recovery. 

ist,  187X,  p.  44. 

Ewens 

7  years  ... 

Ovariotomy ; 
recovery. 

Dermoid     ... 

Unpublished. 

Thornton... 

7  j-ears  ... 

Ovariotomy : 
recovery. 

Dermoid    ... 

Brit.  Med.  Jour.,  1881, 
vol.  ii.  p.  933. 

Lucas 

7  years  ... 

Ovariotomy : 
recovery. 

Alultilocular  cyst. . 

Trans.    Clin.  Soc,  Lon- 
don, vol.  xxi.  p.  224. 

Cupples    ... 

7  yrs.  and 

Ovariotomy  : 

Dermoid    ... 

R  ichmond  <&^  Louisville 

6  mths. 

recovery. 

Med.  and  Surg.  Jour,, 
Dec.  1S74.  {See-Edin. 
Med.   Jour.,  vol.   xx. 
p.  I049-) 

Spencer 

8  years . . . 

Ovariotomy  : 

Dermoid    ... 

Brit.  Med.  Joiir.,  1874, 

Wells. 

recovery. 

vol.  i.  p.  342. 

Leopold   ... 

8  years  . . . 

No  operation 

Cysto-sarcoma 

Aich.Ji'irGyn.,  Bd.  vi. 

Chenoweth 

7  yrs.  and 

Ovariotomy : 

Multilocular 

s,  202. 
Am.  Jonr.   Obstet.,  vol. 

8  mths. 

recovery. 

(weighed  161  lbs.) 

XV.  p.  625. 

Mackenzie 

8  yrs.  and 

Ovariotomy: 

Dermoid    ... 

Dubli7i  Jo7ir.   of  Med. 

6  mths 

recovery. 

Sci.,     1888,      vol.     ii. 

Chenoweth 

8  years  ... 

Ovariotomy : 

Described    as    en- 

p.  302. 
A7n.  Jojtr.    Obstet.,  vol. 

death. 

cephaloid       (sar- 
coma). 

XV.  p.  625. 

Peaslee     ... 

9  years . . . 

No  details. 

Dermoid     

OvarianTuvionrs, p.  59. 

Malins 

9  years . . . 

Ovariotomy  : 
death 

Sarcoma    

Lajicei,  May  31st,  1890, 
p.  1174. 

Dickinson 

10  years  ... 

No  operation 
death. 

Dermoid    ... 

Trans.  Path.  Soc,  vol. 
XXV.  p.  192. 

Wagner    . . . 

ID  years  ... 

Ovariotomy : 
recovery. 

Sarccma    ... 

Arch.fiir  Klin.   Chir., 
Berlin,  1884,  vol.  x.xx. 
P    504- 

Emmet     ... 

ID  5'ears  ... 

No  operation 

Tumour      weighed 

Afu.  Jour.  Obstet.,  vol. 

death. 

probably  50  lbs. 

xiv.  p.  674. 

88 


Diseases  of  the  Ovaries. 


Ta>ile  of  Cases  of  Oophoritic  Tumours  in   Infants   and 
Girls  under  Fifteen  {contimied). 


Reporter. 

Af.E. 

RESULT. 

Ovariotomy : 

Nature  oe 
Tumour. 

Sarcoma    of    both 

Reference. 

Halliday 

1 1  years  . . . 

Obstet.    Trans.,  Edin., 

Croom. 

recoverj'. 

ovaries. 

vol.  xiv.  p.  93, 

Jovion,     of 

12  years ... 

Ovariotomy: 

Multilocular  cyst... 

Gaz.    Heb.,     June     18, 

Nantes. 

abdomen 
opened  by 
caustics  ; 
recovery. 

1869,  p.  396. 

Barlow  and 

12  years  ... 

Ovariotomy : 

Dermoid 

Clin.     Trans.,  Lo7uion, 

Marsh. 

recovery. 

vol.  xi.  p.  175. 

Keith 

12  years  ... 

Ovariotomy : 

Semi-solid    tumour 

Brit.  Med.  Jour.,  1878, 

recovery. 

ascites. . 

vol.  ii.  p.  59?. 

Lee,  Robert 

12  years ... 

No  operation 
death. 

Dermoid     ... 

Medico  -  Chir.  T^'ans., 
vol.  xliii.  p.  103. 

Baker 

13  years  ... 

Incomplete 

Solid  tumour 

Ovarian   Dropsy,    Lon- 

Brown. 

ov.:  death. 

don,  p.  260. 

Baillie. 

12     or     13 

Dissecting- 

Dermoid    ... 

Morbid    A  natomy,     p. 

Matthew. 

years. 

room  subject 

199. 

Griffiths  of 

12  years ... 

Ovariotomy: 

Dermoid    ... 

Trans.   Path.     Society, 

Swansea 

recovery. 

London, '  vol.  xxviii. 
p.  196. 

Schultze  ... 

12  years  ... 

Ovariotomy : 
recovery. 

Dermoid    ... 

Deiit  Zeitsch.fiirPrakt. 
Med.,  1876. 

Wegsch  ei- 

12 years  ... 

No  operation 

Colloid    tumour   of 

Beitrdge  z.    Geburt.    n. 

der. 

death. 

ovary  (Virchow) 

Gyn.  der  Geburt. ;  Ges. 
in     Berlin,     1870,     i. 

P-3S-..          ,        ^,. 

Wagner    . . . 

13  years.. 

Ovariotomy : 
death. 

Sarcoma     ... 

Arch. fur  Klin.  Chir., 
Berlin,  Bd.  xxx.  s. 
504. 

Keith 

13  years  ... 

Ovariotomy : 
recovery. 

Dermoid    ... 

Obstet. _  Joicr.  Gt.  Brit., 
vol.  iv.  p.  31. 

Koeberle  ... 

13  years  ... 

Ovariotomy: 
recovery. 

Multilocular  cyst . . . 

London  Med.  Record, 
Feb.  15th,  1876,  p.  90. 

Bell 

13  years  ... 

Ovariotomy : 

Unilocular         ova- 

Lancet, Feb.  26th,  1887, 

recovery. 

rian  ;    8  pints   of 
fluid. 

p.  418. 

Koeberl6  ... 

13  years  ... 

Cooperation 

Multilocular  cyst... 

Gaz.  Med.  de  S trass- 
burg,  1876. 

Jessop 

13  years ... 

Ovariotomy : 
death. 

Dermoid    

Lancet,  1871,  vol.  ii. 
P-  431- 

Fawcett- 

13^  years  . 

No  operation 

Cyst,    with    blood- 

Trans. Path.  Soc,  Lon-. 

Battye. 

sudden 
death. 

stained  contents ; 
precise        nature 
not   ascertained  ; 
weighed  76  ozs. 

don,  vol.  ii.  p.  280. 

Haward    . . . 

13  yrs.  and 

Ovariotomy : 

Dermoid  ;    twisted 

Lancet,  May  15th,  1886, 

9  mths. 

recovery. 

pedicle. 

p.  920. 

Bryant 

1 4  years  . . . 

Ovariotomy : 
recovery. 

Multilocular 

Gjty's  Hosp.  Rep.,  \o\. 
xiv.  p.  269,  1869. 

Mund6     ... 

14  years  ... 

Electrolysis 
then  ovari- 
otomy :rec. 
by  Thomas 

Dermoid    ... 

Trans.  Anu  Gyn.  Soc, 
\o\.  ii.  ;  1877. 

Smith        ... 

14  years... 

Ovariotomy : 

Malignant    disease 

Lancet,    1874,    vol.    ii. 

death. 

(sarcoma  ?)        0I 
both  ovaries. 

p.  501. 

OVARIAN  Tumours  in  Childhood. 


89 


Table   of  Cases    of  Oophoritic  Tumours   in  Infants  and 
Girls  under  Fifteen  {conchtdea). 


Reporter. 

Ac-.F.. 

Rh.su  LT. 

Nature  of 
Tumour. 

Sarcoma    

Reference. 

Spencer 

13  yrs.  and 

L'apped  ;    no 

OvarJanTianoiirs,  P-  56; 

Wells. 

9  naths. 

operation  ; 
death. 

1882. 

'I'hornton... 

13  years  ... 

Ovariotomy : 

Dermoid  ;    twisted 

Med.-Chir.  Trafts.,  vol. 

recovery. 

pedicle. 

L\x.  p.  65. 

Thornton... 

14  years  ... 

Ovariotomy : 
recovery. 

jMultilocular  cyst.. 

Brit.  Med.  Jour.,  1878, 
vol.  ii.  p.  594. 

Bantock  ... 

14  years  ... 

Ovariotomy : 
recovery. 

Dermoid    ... 

Med.-Chir.  Trans.,  vol. 
Ixiv.  p.  124. 

Leopold    . . . 

14  j'ears  ... 

No  operation 

Sarcoma     

Arch,  fur  Gyn.,  Bd.  vi. 

Spencer 

15  years  ... 

Ovariotomy : 

Cyst            

s.  203. 
OvarianTumours,  1882. 

Wells. 

recovery. 

Bantock  ... 

15  years ... 

Ovariotomy  : 

Inflamed  dermoid  ; 

Med.-Chir.  Trans  ,  vol. 

recovery. 

twisted  pedicle. 

Ixiv.  p.  122. 

Lawson 

[5  years  ... 

Ovariotomy : 

Ovarian  cyst 

Diseases  0/  the  Ova7y, 

Tait. 

recovery. 

P-  319-. 

Thornton... 

15  years  ... 

Ovariotomy : 

Described   as   can- 

Med.  Times  and  Gaz., 

death. 

cer. 

Feb.  24th,  1B83,  p.  211. 

R.  W.  Par- 

Between 

Ovariotomy : 

A  large  multilocu- 

Not  yet  published. 

ker. 

14  and  15 

years. 

recovery. 

lar  cyst. 

Giraldes  ... 

15  years  .. 

Ovariotomy : 

death. 

Dermoid    ... 

Gaz.  Heb.,  March  8th, 
1867,  p.  155. 

Dionys  von 

15  years ... 

Ovariotomy : 

Carcinoma... 

Arch,    far  Gyn.,    Bd. 

Szabo. 

death. 

xxxii.  p.  103. 

Dionys  von 

15  years  ... 

Ovariotomy : 

Dermoid    

Ibid. 

Szabo. 

recovery. 

Koeberle  ... 

14— IS  yrs. 

Ovariotomy : 
recovery. 

Dermoid     ... 

Medical  Record,  Lon- 
don, Feb.  15th,  1876. 

Koeberl^  ... 

14—15  yrs. 

Ovariotomy : 
recovery. 

Dermoid    ... 

Ibid. 

Koeberle  . . . 

15  years  ... 

No  operation 
death. 

Cancer 

Gaz.  Med.  de  Strass- 
burg,  Sept.  ist,  1875. 

An  analysis  of  this  table  of  sixty  cases  may  be  arranged 


thus 


Dermoids. 
28 


Sarcomata. 
16 


Cysts. 
16 


Brief  records  of  a  few  other  cases  were  obtained,  but 
the  details  were  too  meagre  to  allow  of  them  being  in- 
cluded in  the  tables. 

A  study  of  the  various  cases  included  in  this  list 
brings  to  light  some  important  facts.  It  has  long  been 
known  that  a  large  proportion  of  ovarian  tumours  oc- 
curring in  infancy  are  dermoids.     The  cases  in  this  table 


90  Diseases  of  the  Ovaries. 

support   this  opinion,   but    I  was   not  prepared  to    find 
that  sohd  tumours  were  so  frequent. 

When  considering  sohd  ovarian  tumours  it  was  men- 
tioned that  they  formed  in  comprehensive  Hsts  of  ovario- 
tomies about  5  per  cent.,  but  my  table  shows  that  before 
puberty  solid  tumours,  described  either  as  sarcomata  or 
cardno??iata,  form  26  per  cent,  of  the  total  number. 

But  this  is  not  all.  Surgeons  generally  regard  an 
ovarian  dermoid  as  non-malignant.  The  histories  of  the 
patients  show  that  this  is  not  always  so.  In  Jessop's  case 
the  report  runs  thus : — "The  tumour  consisted  of  one  large 
cyst,  with  several  smaller  ones  attached,  and  of  a  mass  of 
white  cheesy  matter,  mixed  with  numerous  thin,  colour- 
less, curly  hairs,  which  on  microscopical  examination 
presented  the  appearance  of  encephaloid.  At  the 
autopsy  cancerous  deposits  were  found  in  the  liver,  right 
supra-renal  capsule,  and  mesenteric  glands." 

Doran*  makes  the  following  important  statement : — 
"  Mr.  Thornton  assures  me  that  he  has  known  several 
cases  where  malignant  deposits  have  recurred  in  the 
pelvis  two  or  three  years  after  the  removal  of  large 
dermoid  cysts,  containing  soft  white  growths  that  strongly 
resemble  sarcomata." 

Thorntonf  has  recorded  a  case  in  which  he  removed 
an  ovarian  dermoid  from  a  woman  in  June,  1881,  and 
she  died  of  recurrence  in  May,  1882.  The  details  are 
unfortunately  very  meagre. 

Many  cases  of  ovarian  dermoids  have  been  described 
in  which  the  reporters  believed  sarcomatous  tissue  to 
have  been  present,  but  such  statements  must  be  received 
with  caution,  because  the  heterogeneous  character  of  these 
tumours  introduces  a  great  element  of  doubt.      Never- 

*   Tumours  of  the  Ovary,  p.  89. 

t  Med.  Times  and  Gazette,  1883,  vol.  ii.  p.  235. 


Oophoroma  ta  . 


91 


theless,  it  seems  to  me  that  the  malignant  tumours  in  the 
ovaries  of  children — termed  by  some  sarcomata,  by  others 
carcinomata — are  histologically  distinct  from  the  common 
forms  of  cancer  or  sarcoma,  and  they  ought  to  be  arranged 
provisionally  in  a  group  by  themselves,  under  the  term 
oiiphoroinata^  because  they  seem  to  be  special  to  the  con- 
nective tissue  of  the  oophoron.  The  distinguishing 
features  of  oopJw7'omata  are  these  : — 

1,  Histologically,  they  repeat  the  characters  of  the 

connective  tissue  of  \\\^  foetal  ovary. 

2.  The   growth    usually  affects  both    ovaries    simul- 

taneously, but  in  a  fair  proportion  of  cases  is 
restricted  to  one  ovary. 


oVeM®  ©     e  ./ 


)©„ 


Fig.  35.— Microscopical  Characters  of  an  Alveolar  Oophoroma.     (After  Doran.) 
A,  Under  low,  E,  under  high,  magnification. 


They  rarely  occur  after  puberty. 

Sometimes  they  occur  in  association  with  ovarian 

dermoids  before  puberty,  and  lead  to  secondary 

deposits. 
They  recur  locally  after  removal. 
In   foetuses    and     very  young   children   the   cell 

elements  preponderate  (Fig.  34). 


92  Diseases  of  the  Ovaries. 

7.  Towards  puberty  they  tend  to  assume  an  alveolar 
arrangement  (Fig.  35),  and  mimic  the  structure 
of  cancer. 

It  is  quite  possible  that  in  those  oophoromata  which 
present  an  alveolar  arrangement,  the  alveoli  represent 
erratic  development  of  immature  ovarian  follicles. 

The  subject  requires  careful  investigation,  and  it 
would  be  interesting  if  those  surgeons  who  have  removed 
ovarian  dermoids  from  children  under  fifteen  years  with 
success,  would  take  the  trouble  to  record  the  subsequent 
histories  of  their  patients  as  far  as  they  have  been  able  to 
follow  them. 

It  is  very  instructive  to  notice,  in  looking  through  the 
tables,  that  in  all  the  instances  where  no  operation  was 
performed  the  patients  died  at  intervals  of  a  few,  months, 
or  one  to  four  years  from  the  time  they  came  under 
observation. 

It  is  also  necessary  to  point  out  that  in  only  a  few 
instances  have  the  tumours  been  submitted  to  a  micro- 
scopical examination.  An  examination  of  the  records  of 
the  cases  in  the  table  disproves  a  statement,  attributed  to 
Koeberle,  that  the  majority  of  tumours  in  the  ovaries  of 
children  are  either  dermoids  or  cysts  originating  in  the 
organ  of  Rosenmiiller.  I  cannot  find  any  trustworthy 
record  of  a  parovarian  cyst  before  the  sixteenth  year. 


93 


CHAPTER  IX. 

PAROOPHORITIC     CYSTS     AND     WARTY     OVARIES. 

It  has  already  been  pointed  out  that  the  ovary  con- 
sists of  two  distinct  parts  :  the  obphoron  2iXi6.  paroophorofi. 
The  latter  contains  remnants  of  the  mesonephros  (Wolffian 
body)  in  various  stages  of  degeneration.  Usually,  the 
paroophoron  in  the  adult  consists  of  fibrous  tissue  per- 
meated by  blood-vessels,  and  receives  the  vertical  tubules 
of  the  parovarium.  In  the  foetus  at  birth,  and  occa- 
sionally in  young  subjects,  it  retains,  in  a  measure,  its 
original  tubular  character.  In  such  specimens  the  struc- 
tural differences  of  the  two  parts  of  the  ovary  are  very 
striking. 

The  cysts  which  arise  in  the  paroophoron  are,  as  a 
rule,  unilocular,  and  differ  from  oophoritic  cysts  in  the 
following  particulars  : — 

1.  They  do   not  affect  the  shape  of  the  ovary  until 

they  have  attained  an  important  size. 

2.  They    always   burrow   between  the   layers   of  the 

mesosalpinx,  and  when  large  make  their  way 
between  the  layers  of  the  broad  ligament  by  the 
side  of  the  uterus. 

3.  The  interior  is  beset  with  warts. 

The  warts  in  such  cysts  vary  greatly  in  number. 
Sometimes  only  a  few  clusters  are  present,  as  in  Fig.  36, 
but  in  others  they  are  so  luxuriant  as  to  cause  the  cyst 
containing  them  to  rupture  (Figs.  37  and  38). 

These  warts  are  very  vascular,  bleed  freely  when 
handled;,  and  are  frequently  calcified. 


94  Diseases  of  the  Ovaries. 

Coblenz  *  was  the  first  to  clearly  identify  and  distin- 
guish these  cysts  from  those  arising  in  the  parovarium, 
and  associate  them  with  definite  structures.  His  observa- 
tions have  been  largely  confirmed  by  Doran,f  who  has 
devoted  great  attention  to  this  question. 

On  one  occasion,  whilst  examining  sections  of  the 


'  I  Fig.  36. — Paroophoritic  Cyst.     (After  Doran.) 
Its  relations  to  the  tube,  ovary,  and  meso-salpinx  are  well  shown. 

ovaries  of  a  seventh-month  foetus,  Doran  detected  in  one 
of  them  three  small  cysts,  almost  of  equal  size,  lying  in  a 
row  along  its  long  axis,  and  plainly  visible  to  the  naked 
eye,  which  could  also  detect  exuberant  vegetations  grow- 
ing from  their  walls.  The  cysts  were  almost  perfectly 
spherical ;  the  largest  measured  one-twelfth,  and  the 
smallest  one-sixteenth,  of  an  inch  in  diameter.  When 
these  cysts  were   examined  under  the  microscope    the 

*  Virchow's  Anhiv,  Bd.  Ixxxiv.  p.  26. 
t   Trans.  Path.  Soc,  vol.  xxxii.  p.  147. 


Papillomatous  Cysts.  95 

Dranched  processes  sprouting  into  the  cysts  were  seen  to 
be  covered  with  cokimnar  epitheh"um,  these  processes 
were,  in  structure,  warts.  After  a  careful  and  detailed 
description  of  these  ovaries,  Doran  came  to  the  reason- 
able conclusion  that  the  small  cavities  were  incipient 
papillomatous  cysts  of  the  paroophoron. 

The  original  description  of  this  important  specimen 
is  illustrated  by  a  photograph  of  one  of  the  sections. 

In  1886  I  examined,  microscopically,  a  large  number 
of  ovaries  obtained  from  human  foetuses,  and  on  one 
occasion  found  a  cyst  somewhat  smaller,  but  identical 
in  its  situation  and  characters  with  those  described  by 
Doran. 

The  distinguishing  feature  of  these  paroophoritic 
cysts  is  that  they  contain  papillomata ;  biU  all  papillo- 
matous cysts  of  the  ovary  are  Jiot  paroophoritic  in  origin. 
It  will  therefore  be  convenient  in  this  chapter  to  consider 
the  subject  of  warts  in  relation  to  the  ovary  and  paro- 
ophoritic cysts.  The  number  of  warts  in  such  cysts 
varies  very  considerably  :  in  the  specimen  represented  in 
Fig.  36  it  contains  one  large  tuft  surrounded  by  a  few 
scattered  nodules,  whereas  in  other  examples  the  cavity 
of  the  cyst  may  be  so  stuffed  with  them  that  it  bursts. 

The  museum  of  the  Royal  College  of  Surgeons, 
London,  contains  an  admirable  specimen  illustrating  this. 
It  is  sketched  in  Figs.  37  and  38.  It  is  thus  described 
in  the  catalogue  : — "  An  uterus  with  its  appendages.  A 
mass  of  finely  lobulated  and  pedunculated  growths  springs 
from  the  site  of  each  ovary,  the  substance  of  which,  with 
follicles,  was  discovered  on  close  search  at  the  roots  of 
the  growths.  These  growths  were  probably  enclosed  at 
an  early  stage  in  a  cyst  wall." 

The  parts  were  removed,  after  death,  from  the  body 
of  a  young  lady  who  died  of  some  visceral  affection. 

It   is    a   matter   of   regret  that    more  facts    are    not 


96 


Diseases  of  the  Ovaries. 


forthcoming  regarding  the  clinical  signs.     There  can  be 
no  doubt  that  the  opinion  expressed  in  the  catalogue  that 


Fig.  37. — Ruptured  Paroophoritic  Cyst  (right  half  of  the  specimen).      (Museum, 
Royal  College  of  Surgeons.) 

the  growths  were  probably  enclosed,  at  an  early  stage,  in 
a  cyst,  is  correct,  for  the  following  reasons  : — 

1.  The  characters  of  the  papillomatous  masses  exactly 

correspond    to    those    found    in    paroophoritic 
cysts. 

2.  The  ovary  is  partially  absorbed  by  the  growth. 

3.  The  mass  has  burrowed  between  the  layers  of  the 

broad  ligament,  and  made  its  way  beside  the 
uterus. 

4.  Remnants  of  the  cyst  wall  are  still  present  in  the 

specimen. 
A  distinction  must  be  drawn  between  rupture  of  the 
cyst  and  perforation  of  the  cyst  wall  by  the  papillomata. 


PaPIL L O ma  to  I  -S     C\ 'S  TS. 


97 


In  the  latter  condition,  cauliflower-like  masses  of  warts 
project  from  the  surface  of  the  cyst  into  the  peritoneal 
cavity  :  sometimes  at  one  spot,  sometimes  in  three  or 
four   places.       In    the    specimen   mentioned   above  the 


UTERUS 


Fig.  38. — Ruptured  Paroophoritic  Cj-st  (left  half  of  the  specimen).     (Museum, 
Roj-al  College  of  Surgeons,) 


cysts  have  ruptured,  for  it  will  be  seen,  on  reference  to 
Fig.  37,  that  the  parts  have  been  beautifully  prepared 
and  dissected,  and  that  the  anterior  layer  of  the  broad 
ligament  is  sharply  indicated;  below  this  the  true  cyst 
wall,  with  the  delicate  texture  so  frequently  displayed  by 
these  cysts,  is  easily  recognised  on  the  right  side. 

The  papillomata  in  these  cysts,  when  they  form  such 
large  dendritic  masses,  are  very  vascular,  and  easily  bleed 
when  manipulated.  The  cells  are  usually  spheroidal  in 
shape,  and  the  stroma  is  very  scanty.  Frequently  the 
warty  masses  undergo  calcification. 

An  important  pathological  and  clinical  fact  connected 
H 


98  Diseases  of  the  Ovaries. 

with  these  cysts  is,  that  when  they  rupture  the  fluid  they 
contain  is  scattered  broadcast  over  the  peritoneum. 
Doran  *  briefly  relates  a  case  of  this  kind  : — 

"  The  patient  was  forty-six  years  of  age  ;  the  cyst  had 
burst,  and  the  bladder,  uterus,  and  pelvic  peritoneum 
were  studded  with  papillary  growths.  The  cyst  had 
forced  itself  between  the  layers  of  the  broad  ligament, 
and  grown  backwards,  pushing  itself  under  the  peri- 
toneum, until  at  one  point  its  walls  touched  the  common 
iliac  arteries.  It  was  mostly  enucleated.  The  patient 
died  on  the  fifth  day.  There  was  thrombosis  of  the  right 
femoral  vein,  which  accounted  for  a  swollen  state  of 
the  right  lower  extremity  before  the  operation.  The 
papillomatous  deposits  had  reached  the  peritoneal  lining 
of  the  diaphragm." 

This  case,  though  briefly  recorded,  not  only  indicates 
the  risks  w^hich  patients  run  from  the  rupture  of  such 
cysts  inducing  general  infection  of  the  peritoneum,  but 
also  the  difficulties  which  beset  the  operation  when  they 
are  of  large  size  and  burrow  deeply  and  extensively  under 
the  pelvic  peritoneum. 

When  there  is  general  papillomatous  infection  of  the 
peritoneum,  the  warts  are  most  numerous  on  the  serous 
membrane  lining  the  recto-vaginal  pouch,  and  on  the 
omentum  and  mesentery. 

When  paroophoritic  cysts  are  of  moderate  size  and 
have  not  burrowed  deeply,  the  broad  ligament  and  tube 
will  form  a  pedicle,  which  may  be  ligatured  as  easily  as  in 
parovarian  cysts. 

The  papillomatous  infection  of  the  peritoneum  when 
these  cysts  burst  is  also  interesting.  It  has  been  clearly 
established  that  when  the  abdomen  has  been  opened  for 

*  Clinical  and  Pathological  Observations  on  Tmnours  of  the  Ovaries, 
p.  70. 


Pa  pilloma  to  us   Cysts, 


99 


the  removal  of  a  papillomatous  cyst,  the  peritoneum  has 
been  found  studded  with  warts.  A  few  years  later  the 
abdomen  has  been  re-opened,  and  all  the  peritoneal  warts 
have  disappeared.  Thus  they  behave  like  warts  on  the 
skin.  This  fact  must  be  borne  in  mind,  or  the  operator 
will  hastily  assume  the  disease  to  be  malignant  w^hen  he 
finds  general  peritoneal  infection. 

An  analysis  of  trustworthy  lists  of  ovariotomy  cases 


Fig.  39. — Papillary  Cj-st  growing  between  the  Layers  of  the  broad  Ligament, 

near  the  Tubo-ovarian  Ligament.     {Brit.  Gyn.  Soc.) 

A,  Ovary ;  P,  parovarium ;  E,  pedicle  of  the  cj-st ;  F,  Fallopian  tube. 

shows  that  papillomatous  paroophoritic  cysts  are  rare 
before  the^twenty-fifth  year ;  the  period  of  life  in  which 
they  are  most  frequent  is  between  the  twenty-fifth  and 
fiftieth  years. 

Peritoneal  infection  may  ensue  when  such  cysts  are 
tapped,  if  any  of  the  fluid  escape  into  the  abdominal 
cavity.     Tapping  is  therefore  inimical  to  the  patient. 

Papillomatous  cysts  arising  in  the  paroophoron  are 
sometimes  associated  with  dermoids,  and  even  sarcomata 
of  the  ovary. 

There  is  a  form  of  papillomatous  cyst  which  arises 

H    2 


loo  Diseases  of  the  Ovaries. 

in  connection  with  the  ovary,  unconnected  with  the 
paroophoron. 

The  first  specimen  which  came  under  my  notice  is 
represented  in  Fig.  39.  The  ovary,  parovarium,  and 
Fallopian  tube  are  quite  normal.  Growing  between  the 
layers  of  the  mesosalpinx,  quite  close  to  the  tubo-ovarian 
ligament,  is  a  small  cyst  containing  two  separate  loculi. 
The  cyst  wall  is  attached  to  the  ovary  ?jy  a  narrow 
pedicle,  marked  b  in  the  drawing.  The  interior  of  each 
cyst  contained  some  small  cauliflower-like  tufts  of  papillo- 
mata.  The  bases  of  these  warty  tufts  were  formed  of  dense 
fibrous  tissue,  and  the  warts  themselves  felt  hard  and 
resisting,  like  cartilage.  The  cysts  did  not  arise  m  the 
parovarium ;  the  tubules  of  this  structure  were  dissected, 
as  shown  in  the  sketch,  and  found  to  be  quite  distinct. 

A  second  specimen  which  came  into  my  possession  is 
of  some  interest  as  showing  the  care  necessary  to  be 
exercised  in  deciding  the  nature  of  cysts  found  in  this 
part  of  the  mesosalpinx.  The  parts  are  sketched  in 
Fig.  40.  Occupying  the  mesosalpinx,  exactly  in  the 
position  of  the  parovarium,  was  a  cyst  about  the  size  of 
a  cherry.  On  superficial  examination  it  appeared  like 
an  incipient  parovarian  cyst.  On  cutting  into  it  a 
tuft  of  warts  of  almost  cartilaginous  hardness  was  found 
in  its  interior,  and  the  fluid  which  escaped  from  it 
was  like  milk  in  colour.  This  led  to  a  very  careful 
examination  of  the  parts,  and  dissection  showed  that 
the  cyst  was  unconnected  with  the  parovarian  tubules. 
If  we  could  trust  to  the  presence  of  warts  alone  it 
would  be  reasonable  to  infer  that  this  cyst  was  an 
ordinary  paroophoritic  cyst  in  an  incipient  stage,  but  on 
examining  the  surface  of  the  ovary  opposite  to  the 
paroophoron  there  was  a  second  cyst  scarcely  larger  than 
a  pea.  On  opening  this,  the  same  milky  fluid  escaped, 
and  a  tiny  tuft  of  warts  jutted  into  its  cavity. 


l^ARTv   Ovarian   Cysts. 


lOI 


Among  my  collection  of  specimens  at  the  Middlesex 
Hospital  illustrating  this  branch  of  pathology  there  is 
an  ovary  enlarged  in  consequence  of  cysts  to  twice  its 
natural  size.  The  cysts  are  of  two  varieties  ;  the  larger 
occupy  the  substance  of  the  ovary,  but  the  smaller  are 


CYST  WITH  WARTS 


CYST  WITH  WARTS 
Fig.  40. — Warty  (not  Paroophoritic)  Cysts  of  the  Ovary.     Natural  size. 


situated  immediately  beneath,  and  project  the  serous 
coat.  Both  varieties  of  cyst  contain  the  small  hard  white 
warts  such  as  existed  in  the  specimen  from  which  Figs. 
39  and  40  were  drawn.  In  some  parts  of  the  ovary  the 
warts  projected  freely  from  the  surface,  but  it  was  easy 
to.  show  that  the  papillomata  had  been  originally  enclosed 
in  cysts,  because  around  some  of  the  exposed  masses 
remnants  of  the  cyst  wall  were  detected. 


I02  Diseases  of  the  Ovaries. 


PAROVARIUM 


Fig.  41. — Warty  Cyst,  burrowing  between  the  layers  of  the  Mesosalpinx  alons 

the  Tubo-ovarian  Ligament.     Natural  size. 

The  tube  is  17  cm.  in  lengtli. 


IVartv   Ovarian    Cvsts.  103 

It  is  necessary  to  mention  that  three  out  of  five  of 
my  specimens  of  warty  ovaries  were  removed  from 
patients  with  large  uterine  myomata. 

Papillomatous  cysts  of  this  kind  differ  from  paro- 
ophoritic cysts  in  the  following  manner  : — 

1.  They  are  usually  multiple. 

2.  The  cysts  occur  in  any  portion  of  the  ovary. 

3.  The  warts  are  of  almost  cartilaginous  hardness. 

4.  There  is  no  evidence  that  such  cysts  ever  attain 

sufficient   size    to    render  them    dangerous    to 
life. 

5.  Such  cysts  are  frequently  associated  with  uterine 

myomata. 

Another  curious  feature  of  warty  cysts  springing  from 
the  neighbourhood  of  the  parovarium  is  that  they  exhibit 
a  great  tendency  to  burrow  between  the  layers  of  the 
mesosalpinx  along  the  tubo-ovarian  ligament,  quite  away 
from  the  parovarium.  This  is  indicated  in  Figs.  39  and 
40,  but  is  better  seen  in  Fig.  41.  When  fresh,  these 
cysts  are  sometimes  translucent,  and  it  is  impossible  to 
be  sure  of  the  presence  or  absence  of  warts  without 
opening  them. 

When  the  cysts  are  as  large  as  in  the  specimen 
sketched  above,  the  Fallopian  tube  is  usually  much  elon- 
gated. This  stretching  is  probably  due  to  the  tension 
exerted  by  the  cyst  swinging  at  the  distal  end  of  the 
tube. 

Literature  of  Paroophoritic  Cysts. — Thornton  :  Trans.  Path.  Soc, 
vol.    xxviii.    p.    189  ;    Coblenz  :    Virchow's    Archiv,   Bd.    Ixxxiv. 
s.  26  ;  Tait :  Diseases  of  Ovaries,  p.  147,  1883;  Doran  :    Tumours  of 
the  Ovaries,   1884,  and  Trans.  Path.   Soc,  vols,  xxxii.   p.    147,    and 
xxxiii.  p.  207. 


I04 


CHAPTER  X. 

PAROVARIAN      CYSTS. 

The  parovarium  consists  of  a  series  of  narrow  tubules 
situated  between  the  layers  of  the  mesosalpinx,  and 
closely  associated  with  the  paroophoron.  It  is  easily 
seen,  when  the  mesosalpinx  is  stretched  and  held  between 
the  eye  and  the  light,  as  a  series  of  tubules  radiating 
from  the  ovary  to  join  a  longitudinal  tubule  situated  at 
a  right  angle  to  them.  Although  the  tubules  converge 
as  they  approach  the  ovary,  nevertheless  they  remain 
distinct.  Each  tubule  ends  blindly,  and  is  usually  lined 
with  epithelium.  In  form,  size,  and  disposition  they 
resemble  the  arrangement  of  the  vasa  efferentia  of  the 
testis.  This  resemblance  was  observed  by  Rosenmiiller, 
who  discovered  this  structure  in  1801  whilst  prosecuting 
anatomical  researches  at  Erlangen.  The  parovarium  is 
homologous  with  the  vasa  efferentia  and  epididymis  of 
the  testis,  for  these  tubular  structures  in  the  male  and 
female  are  the  persistent  excretory  ducts  of  the  Wolffian 
body  (mesonephros).  In  the  female  they  are  vestigial, 
whereas  in  the  male  they  are  functional. 

When  present  in  its  typical  condition,  the  parovarium 
consists  of  three  parts  (Fig.  42)  :  an  outer  series  of 
tubules,  free  at  one  extremity,  known  as  Kobelt's  tubes ; 
an  inner  set,  termed  the  vertical  tubules.  The  parovarium 
contains,  as  a  rule,  twelve  tubules  ;  sometimes  as  many 
as  seventeen  .may  be  counted,  and  in  other  specimens 
as  few  as  five.  Lastly,  there  is  a  larger  tube  running 
at   right    angles    to    the     vertical    tubules     which    may 


The  Parovarium. 


105 


occasionally  be  traced  downwards  to  the  vagina.  This 
is  Gartner's  duct  ;  it  corresponds  to  the  vas  deferens  in 
the  male. 

The  cysts  that  arise  in  the  parovarium  are  of  two 
kinds.  The  most  frequent  are  small  pedunculated  cysts 
connected  with  Kobelt's  tubes.     As  they  rarely  exceed  a 


ill/'/  <-.       --^ 


^Mm 


Fig.  42. — The  Parovarium  (semi-diagrammatic). 

A,  Oophoron ;  E,  paroophoron;  K,  Kobelt's  tubes;  C,  vertical  tubes  of  the  parovarium  : 

G,  Gartner's  duct. 


pea  in  size,  they  do  not  call  for  much  comnlent,  as  they 
are  of  no  clinical  importance.  They  need  to  be  men- 
tioned, however,  because  they  are  often  confounded 
with  the  hydatid  of  Morgagni.  The  distinction  between 
the  two  structures  is  given  on  page  229.  Occasionally 
some  of  the  vertical  tubules  will  break  loose  and  form 
pedunculated  cysts.  Should  the  cyst  rupture,  it  may  be 
converted  into  a  tuft  of  fimbriae.  The  most  important  cysts 
are  sessile,  and  remain  between  the  layers  of  the  meso- 
salpinx.    In  the  early  stages  it  is  easy  to  demonstrate 


io6 


Diseases  of  the  Ovaries. 


the  relation  of  these  cysts  to  the  parovarium.  When 
such  a  cyst  enlarges  it  burrows  between  the  layers  of  the 
mesosalpinx  and  makes  its  way  towards  the  Fallopian 
tube,  which  becomes  stretched,  because  the  abdominal 
end  of  the  tube  is  fastened  firmly  to  the  ovary  by  the 
tubo-ovarian  ligament,  and  the  ovary  in  its  turn  is  attached 


Fig.  43. — A  Cyst  of  the  Parovarium,  showing  its  relation  to  Ovary  and  Tube. 
Two-thirds  its  natural  size. 

A,  Oophoron  ;  B,  paroophoron  ;  F,  Fallopian  tube. 


to  the  side  of  the  uterus.  In  a  very  large  cyst  the  Fal- 
lopian tube  becomes  greatly  elongated ;  I  have  known  it 
to  attain  a  length  of  40  cm.  In  spite  of  this  extreme 
stretching,  the  lumen  of  the  tube  is  rarely  obstructed,  and 
its  abdominal  ostium  can  usually  be  found,  the  fimbriae 
being  indicated  by  a  few  wattle-like  processes  (Fig.  43). 

Small  cysts  are,  as  a  rule,  transparent,  but  when 
they  exceed  the  size  of  a  cocoa-nut  this  transparency 
is  lost,  and  the  walls  become  thick  and  tough.  Small 
parovarian  cysts  are  lined  with  columnar  epithelium, 
which  is   sometimes  ciliated  ;  in  cysts  of  moderate  size 


Parovarian   Cysts.  107 

the  epithelium  becomes  stratified,  and  in  large  cysts  it 
atrophies  from  pressure. 

The  fluid  they  contain  is  clear  and  limpid  ;  specific 
gravity  loio,  reaction  slightly  alkaline.  An  albuminous 
substance,  precipitated  by  nitric  acid  and  by  alcohol,  is 
present  in  large  quantity. 

The  points  which  enable  a  large  parovarian  cyst  to 
be  distinguished  from  an  oophoritic  cyst  are  these  : — 

1.  The  peritoneal  coat  is  easily  stripped  off. 

2.  The  ovary  is  usually  found  attached  to  the  side  of 

the  cyst. 

3.  The  cyst  is  usually  unilocular. 

4.  The  Fallopian  tube  is  stretched  over  the  cyst,  and 

never  communicates  with  it. 

5.  Specific  gravity  of  the  fluid  does  not  exceed  10 10, 

and  may  be  much  lower. 

6.  In  some  specimens  the  tissue  of  the  mesosalpinx 

stretched     by     the    tumour    becomes    greatly 

thickened. 
It  was  formerly  believed  that  cysts  originating  in  the 
parovarium  rarely  exceeded  the  size  of  an  orange,  but  in 
1873  Dr.  Bantock  *  demonstrated  beyond  any  doubt 
that  parovarian  cysts  may  attain  very  large  proportions, 
and  be  capable  of  containing  several  pints  of  fluid.  The 
chief  rules  laid  down  by  Dr.  Bantock  to  serve  for  the 
recognition  of  parovarian  cysts  are  those  given  above. 
The  conclusions  arrived  at  by  this  surgeon  have  been 
confirmed  by  subsequent  investigators ;  and  there  can 
be  no  doubt  that  in  the  lists  of  the  early  ovariotomists 
many  of  the  so-called  unilocular  cysts  of  the  ovary  were 
parovarian  in  origin.  My  own  observations  on  recent 
and   old   museum    specimens    serve    to    convince    me 

*  "  On  the  Pathology  of  certain  so-called  Unilocular  Ovarian  Cysts, " 
in  Trans.  Obstet,  Soc,  Lotidoii,  vol.  xv.  p.  105. 


io8  Diseases  of  the  Ovaries. 

of  this  fact,  and  of  the  correctness  of  Dr.  Bantock's 
conclusions. 

The  age  at  which  parovarian  cysts  occur  is  of  some 
interest.  It  has  already  been  mentioned  that  oophoritic 
cysts  are  encountered  at  any  period  of  life,  from  foetal 
life  up  to  extreme  old  age.  The  occurrence  of  a  paro- 
varian cyst  has  not,  as  far  as  I  am  aware,  been  recorded 
in  an  individual  before  the  age  of  sixteen.  I  have  col- 
lected many  undoubted  cases  at  seventeen,  eighteen, 
and  nineteen,  in  which  the  cysts  were  large  enough  to  be 
detected  above  the  pubes.  Before  sixteen  the  paro- 
varium appears  to  be  quiescent,  but  on  the  advent  of 
puberty  it  seems  to  undergo  great  stimulation,  A  very 
large  proportion  of  cysts,  generically  classed  as  ovarian, 
removed  between  the  ages  of  seventeen  and  twenty-five, 
arise  in  this  interesting  structure. 

It  is  difficult  to  come  to  any  satisfactory  conclusion 
as  to  the  relative  frequency  of  parovarian,  as  compared 
with  paroophoritic  and  oophoritic  cysts,  until  operators 
become  less  casual  in  their  use  of  the  term  ovarian  cyst. 
With  our  present  knowledge,  they  form  about  ten  per 
cent. 

Parovarian  cysts  do  not  often  contract  adhesions, 
even  when  of  large  size.  The  layers  of  the  broad  liga- 
ment stretched  over  them  occasionally  contain  an 
unusually  large  proportion  of  unstriped  muscle-fibre. 
Parovarian  cysts  rarely  suppurate,  even  when  tapped, 
and  as  this  procedure  cannot  be  depended  upon  to  cure 
them,  it  is  now  abandoned  as  unsatisfactory,  apart  from 
its  risks.  Like  other  forms  of  cysts  and  tumours  related 
to  the  ovary,  they  are  liable  to  axial  rotation  and  com- 
plete detachment.  An  example  of  this  is  illustrated  in 
Fig.  44. 

The  parts  were  removed  by  Dr.  \Valter,  of  Man- 
chester,  and   he  kindly  placed  them  in  my  hands  for 


Rotation  of  Parovarian   Cysts. 


109 


BRIi^E 


Fig.    44. — Ovary  and    Stump  of  a  Fallopian    Tube,   left    after  axial   rotation, 

ending  in  complete  detachment  of  a  Parovarian  Cyst.     (Dr.  Walter's  case.) 

*  The  rounded  stump  of  the  tube  at  the  point  of  detachment. 


no  Diseases  of  the  Ovaries. 

examination.  The  cyst  is  clearly  parovarian,  and  is 
embedded  in  the  mesosalpinx.  The  fimbriated  end  of  the 
tube  and  a  small  pedunculated  cyst  are  connected  with  it. 
The  cyst  was  adherent  to  the  back  of  the  uterus.  The 
veins  in  the  corresponding  broad  ligament  were  varicose. 
For  fuller  details  relating .  to  axial  rotation  of  cysts  and 
tumours,  see  chapter  xiii. 

Epithelium. — It  was  formerly  the  custom  to  believe 
in  the  immutability  of  epithelium ;  hence  many  writers 
have  relied  upon  the  characters  of  the  epithelial  lining  of 
cysts  as  indicative  of  their  origin.  Mutation  of  epithe- 
lium has  been  proved  so  often,  that  it  is  needless  to 
do  more  than  mention  that  in  some  parovarian  cysts 
ciliated  cells  will  be  found ;  in  other  simple  cubical,  and 
in  many  large  cysts,  no  epithelium  can  be  detected.  Un- 
doubted parovarian  cysts  sometimes  present  low  flat- 
topped  warts. 


Ill 


CHAPTER   XL 

OVARIAN      HYDROCELE. 

In  1853  Richard  described,  under  the  term  tubo-ovarian 
cyst,  a  variety  in  which  the  Fallopian  tube  opened 
directly  into  the  cavity  of  a  cyst  by  a  large  circular  or 
elliptical  aperture,  representing  the  abdominal  orifice  of 
the  tube. 

Tubo-ovarian  cysts  have  been  described  several  times 
since  Richard  drew  attention  to  them.  These  descrip- 
tions have  been  collected  and  analysed  by  Dr.  Griffith. 
None  of  the  observers  appear  to  have  appreciated  the 
nature  of  these  curious  cysts. 

It  will  be  more  appropriate  to  call  them  ovarian  hydro- 
celes^ because  there  is  good  reason  to  believe  that  they  arise 
in  a  tunic  of  peritoneum  that  occasionally  invests  the 
ovary,  much  in  the  same  way  that  the  tunica  vaginalis 
clothes  the  testis.  Before  submitting  evidence  in  support 
of  this  view,  it  will  be  well  to  describe^^a  few  typical 
specimens. 

A  good  example  is  sketched  in  Fig.  45  :  the  cyst  was 
removed  from  a  woman  forty-three  years  of  age.  She  had 
noticed  a  swelling  in  her  abdomen  for  three  years.  Clini- 
cally it  presented  the  characters  of  a  cyst  occupying  the 
broad  ligament.  At  the  operation  it  was  found  intimately 
incorporated  with  the  broad  ligament,  and  this  caused 
some  difficulty.  It  contained  three  pints  of  straw- 
coloured  fluid. 

On  dissecting  the  specimen,  the  Fallopian  tube  was 
found  dilated  and  contorted;  its  distal  end  communi- 
cated with  the  interior  of  the  cyst  by  an  oval  aperture. 


112 


Diseases  of  the  Ovaries. 


On  examining  the  walls  of  the  cyst  microscopically, 
no  epithelium  was  detected.  The  orifice  by  which  the 
tube  and  cyst  communicate  corresponds  to  the  abdominal 


Fig.  45.— Ovarian  Hydrocele.     {Trans.  Ohstet.  Soc.) 
F,  Fallopian  tube  ;  v.  uterus. 


ostium  of  the  tube,  and  the  ridges  which  radiate  there- 
from were  directly  continuous  with  the  folds  of  mucous 
membrane  within  the  tube.  In  this  specimen  no  trace 
of  the  ovary  was  visible.     The  nature  of  this  form  of  cyst 


Ovarian  Hydrocele. 


113 


is  more  clearly  set  forth  in  the  specimen  shown  in  Fig. 
46.  This  came  into  my  hands  in  a  recent  condition, 
and  on  reference  to  the  sketch  it  will  be  noticed  that 
the  tube  is  widely  dilated  toward  its  ampulla,  and  then 
opens  by  a  wide  orifice  into  an  oval  cyst  the  size  of  an 


osTruM 


FIMBRI/C 


Fig.  46.  — Ovarian  Hydrocele.     Natural  size.     (Dr.  Walter's  specimen.) 


egg.  Projecting  into  the  floor  of  the  cyst  is  a  portion  of 
the  ovary  ;  the  remainder  of  the  ovary,  though  adherent 
to  the  cyst  wall,  lies  outside  the  cyst,  and  presents  a 
recent  corpus  luteum. 

The  cyst  wall  was  directly  continuous  with  the  broad 
ligament.  On  examining  the  orifice  by  means  of  which 
the  tube  and  cyst  communicated,  small  atrophied,  but 
unmistakable,     Fallopian    fimbriae     were    found.      The 


114 


Diseases  of  the  Ovaries. 


examination  of  this  specimen  threw  much  new  Hght  on 
the  subject. 

We  must,  in  order  to  appreciate  these  cysts,  deal  with 
a  few  points  relating  to  the  peritoneal  relations  of  the 
ovary. 

The  ovary  projects  from,  and  is  invested  by,  the 
posterior  layer  of  the  broad  ligament.     When  the  parts 


ROUND    LIQT 


Fig.    47. — The   Ovarian  Sac  or  Recess  on   the   posterior   aspect  of  the  Broad 
Ligament  (human).     (Modified  from  Richard.) 


are  examined  in  situ,  the  ovary  will  be  found  to  lie  in,  or 
upon,  the  edge  of  a  shallow  recess  in  the  mesosalpinx. 
This  recess  is  the  ovarian  sac.  It  varies  in  depth :  in 
many  it  is  small  and  inconspicuous,  whilst  in  others  it  is 
sufficiently  deep  to  accommodate  the  entire  ovary.  In 
the  virgin  the  ampulla  of  the  tube  falls  over  the  mouth 
of  this  recess  and  conceals  the  ovary.  This  relation  of 
parts  is  usually  disturbed  in  the  first  pregnancy.  The 
position  of  this  pouch  is  shown  in  Fig.  47,  which  is 
slightly  modified  from  the  well-known  figure  introduced 


The   Oi^ARiAN  Sac. 


115 


by  Richard,  185 1.  In  this  drawing  the  parts  are  repre- 
sented as  seen  from  the  front,  the  tube  and  mesosalpinx 
being  drawn  forward  in  order  to  put  the  parts  on  the 
stretch. 

In  many  mammals  the  ovarian   sac  is  much  deeper 
than  in  the  human  female.     In  such  a  mammal  as  the 


OVARY 


OSTIUM  TUB/E 


Pig.  48. — Transverse  Section  of  the  Ovary  and  Ovarian  Sac  of  a  Mouse. 
(After  Robinson.) 


hygena  {Hycena  croaitd)  it  forms  a  complete  tunic  to  the 
ovary,  and  the  cavity  of  the  sac  communicates  with  the 
general  peritoneal  cavity  by  a  very  small  fringed  orifice. 
In  rats  and  mice  the  sac  is  complete,  so  that  the  ovary  is 
isolated  from  the  general  peritoneal  cavity.  As  the 
Fallopian  tube  opens  into  the  ovarian  sac,  it  follows 
that  in  such  forms  as  the  hyaena,  or  the  tigress,  the  tube 
opens  into  the  peritoneal  cavity  by  way  of  the  ovarian 
sac.  In  rats  and  mice  the  Fallopian  tubes  communicate 
I  2 


ii6 


Diseases  of  the  Ovaries. 


with  the  ovarian  sacs,  but  not  with  the  general  peritoneal 
cavity. 

The  sac  in  some  mammals  invests  the  ovary  loosely, 
whilst  in  others,  as  the  raccoon,  it  fits  it  tightly,  and 
corresponds  with  its  eminences  and  depressions.  These 
ovarian  sacs,  with  the  exception  of  the  complete  form 
exhibited  by  rats  and  mice,  have  long  been  known  to 


TUBO    ov 
LIGT 


^  UTERUS 


OVN    LIGT  N\ 

Fig,  49.— Ovarian  Sac  of  a  Baboon.     (After  Robinson.) 


anatomists,  but  it  remained  for  Mr.  Arthur  Robinson  not 
only  to  detect  the  complete  form,  but  to  demonstrate  the 
manner  in  which  they  arise. 

Stages  in  the  formation  of  these  sacs,  intermediate  to 
the  shallow  recess  in  the  human  female  and  the  complete 
pouch  of  the  mouse,  may  be  studied  in  the  baboon  and 
porcupine  (Figs.  49  and  50). 

An  examination  of  the  sac  in  the  porcupine  shows 
that  when  the  ovary  lies  in  the  recess,  the  margins  of 
the  cavity  come  into  contact ;  in  the  figure  they  are 
represented   widely   separate,   in    order    to    display   the 


The    Ovarian  Sac. 


117 


relation  of  the  parts.  Should  the  edges  unite,  then  a 
complete  sac,  such  as  is  represented  in  Fig.  48,  would 
be  formed.  For  full  details  reference  should  be  made 
to  Robinson's  admirable  paper.^  When  the  ovary  is 
furnished  with  a  complete  sac  of  this  kind  it  resembles 
the  testis,  with  its  tunica  vaginalis",  except  that  the  Fal- 
lopian tube  directly  communicates  with  it, 

Lawson  Tait  f  writes  : — "  In  a  few  exceptions  I  have 


OVARIAN  SAC 


Fig.  50.— Ovarian  Sac  of  a  Porcupine.     (After  Robinson.) 

seen  a  crescentic  double  fold  of  the  posterior  layer  of  the 
broad  ligament  pass  down  behind  the  ovary,  covering  it 
like  the  hood  of  a  '  Nepenthes '  gland.  In  all  such  cases 
the  women  have  been  sterile,  probably  because  this  hood 
has  prevented  the  application  to  the  ovary  of  the  opening 
of  the  oviduct.  I  have  seen  this  arrangement  give  great 
trouble  in  the  removal  of  small  ovaries." 

Being  acquainted  with  the  existence  of  ovarian  sacs, 
I    have    been    on    the     watch    for    several    years    for 


*  "On  the  Peritoneal  Relations  of  the  Mammalian  Ovary  ;  "  Journal 
o   Anatomy  and  Physiology,  vol.  xxi.  p.  169. 
+  Diseases  of  the  Ovaries,  p.  6  ;   1883, 


ii8 


Diseases  of  the  Ovaries. 


specimens  in  which  they  had  become  converted  into 
hydroceles. 

Schneidemlihl*  has  described  and  figured  a  specimen 
which  he  found  in  a  mare  (Fig.  51). 

Dr.  Robinson  kindly  placed  at  my  disposal  two 
specimens,  obtained  from  white  rats,  in  which  the  ovarian 
sacs  were  distended  with  pus. 

The  museum  of  University  College,  London,  contains 


TUBE 


Fig.  51. — Ovarian  Hj-drocele  from  a  Mare.     (After  Schneidemlihl.) 


a  specimen  formerly  described  as  an  example  of  double 
ovarian  cysts  in  a  guinea-pig.  As  the  peritoneal  relations 
of  the  ovaries  in  this  rodent  are  identical  with  those  of 
the  porcupine,  I  suspected  that  these  supposed  ovarian 
cysts  were  probably  hydroceles  ;  on  dissecting  the  parts, 
with  the  kind  permission  of  Mr.  Stonham,  it  was  easy 
to  determine  that  the  cysts  were  largely  dilated  ovarian 
pouches,  and  the  Fallopian  tubes  ran  round  them,  the 
abdominal  ends  being  directly  continuous  with  the  sac 
wall.  In  the  smaller  tumour  the  Fallopian  tube  dilates 
as   it  approaches   the  abdominal   end,  and  opens  by  its 

*  Zeitschiift fiir  Thier/nedccin,  Bd,  ix.  s.  279, 


Ovarian  Hydrocele. 


119 


ostium  into  the  sac.  In  the  larger  cyst  the  orifice  is 
obliterated.  The  ovaries  on  both  sides  are  cystic,  and 
project  into  the  sacs  of  the  hydroceles  with  which  they 
are  associated  (Fig.  52). 

During  life  the  guinea-pig  was  thought  to  be  pregnant; 


OVARY 


OSTIUM  OF  TUBE 


Fig.    52.— Ovarian    Hj-droceles    in    a    Guinea-pig,      (Museum    of    University 

College.) 

it    died    with   convulsions    resembling    those    seen    in 
uraemia. 

An  excellent  specimen  of  ovarian  hydrocele  is  pre- 
served in  the  museum  of  St.  Bartholomew's  Hospital. 
It  has  been  described  by  Dr.  Griffith^  as  a  tubo-ovarian 
cyst,  but  from  his  account  of  the  specimen  I  came  to  the 
opinion  that  it  was  a  hydrocele,  and  obtained  permission 
to  re-examine  it. 

*  "Tubo-Ovarian  Cysts;"    Trans,  of  the  Ohstetrical  Society,   vol. 
jcxix.  p.  273 ;  1887. 


T20 


Diseases  of  the  Ovaries. 


The  uterus  and  the  left  ovary  and  tube  are  normal. 
Projecting  from  the  back  of  the  right  broad  ligament  is  a 
thin-walled  unilocular  cyst,  measuring  five  inches  by 
three  and  a  half  inches.  The  ovarian  ligament  passes  from 
the  uterus  to  the  cyst  wall,  and  at  this  spot  ovarian  tissue 


rUBE 


OSTIUM 


Fig.  53- — Ovarian  Hydrocele.     (Museum,  St.  Bartholomew's  Hospital.) 


can  readily  be  seen,  as  Dr.  Griffith  points  out  in  his 
original  account  of  the  case.  The  Fallopian  tube 
measures  nine  inches  in  length ;  its  outer  third  is  greatly 
distended,  but  the  inner  two-thirds  are  not  enlarged. 
The  abdominal  extremity  is  adherent  to  the  cyst,  and 
■communicates  with  it  by  a  large  circular  opening  two 
inches  in  diameter.  No  traces  of  the  fimbriae  are  visible 
on  the  inner  or  outer  surfaces  of  the  cyst  (Fig.  53). 

The  contents  of  the  cyst  were  unfortunately  lost,  but 
the  fluid  was  thin,  watery,  and  almost  colourless.     The 


Intermitting    Ovarian  Hydrocele.         121 

specimen  has  no  clinical  history,  and  was  removed  at 
the  post  mortem  examination  of  a  woman  twenty-seven 
years  of  age,  who  died  three  years  and  a  half  after  a 
severe  injury  to  the  spine,  causing  paraplegia.  There  is 
no  history  as  to  the  duration  of  the  cyst. 

The  peculiarities  of  ovarian  hydroceles  may  be  sum- 
marised thus  : — 

1.  The  Fallopian  tube  opens  by  its  abdominal  ostium 

into  a  sac  on  the  posterior  aspect  of  the  broad 
ligament. 

2.  The  tube  is  elongated,  dilated  and  tortuous,  and, 

as  Griffith  aptly  expresses  it,  the  general  outline 
of  the  parts  resembles  ''''a  i-etort  zoith  a  con- 
voluted delivery  tubey 

3.  As  a  rule,  there  is  no  evidence  of  inflammation. 

The  cyst  may  suppurate  should  the  tube 
become  affected  with  salpingitis. 

4.  In  small  cysts  the  ovary  will  be  found  projecting 

on  the  floor  of  the  sac.     In  larger  specimens  it 
will  be  incorporated  with  the  wall  of  the  sac, 
and  in  very  large  specimens  is  unrecognisable. 
Ovarian  hydroceles   must   not   be  confounded  with 
tubo-ovarian  cysts;   on   the  other  hand,   a  suppurating 
ovarian  hydrocele  must  not  be  confounded  with  a  tubo- 
ovarian  abscess. 

Intermitting  ovarian  hydrocele  {hydrops  tiibce  pro- 
fluens). — An  ovarian  hydrocele  differs  from  hydro-  or 
pyo-salpinx  in  the  fact  that  it  may  intermit :  that  is,  the 
fluid  which  it  contains  sometimes  escapes  through  the 
tube  into  the  uterus,  and  is  discharged  externally.  Dr. 
Barnes  mentions  a  case  of  this  sort  which  occurred  to 
Mr.  Anderson.  A  woman  with  an  abdominal  cyst,  waiting 
to  be  tapped,  suddenly  passed  what  was  supposed  to  be 
an  excessive  quantity  of  urine.  The  fluid  was  found  to 
be  albuminous,  and  contained  cholesterine.     Six  months 


122  Diseases  of  the  Ovaries. 

later  she  died  from  hsemoptysis,  and  a  large  empty  cyst, 
with  secondary  cysts  in  its  walls,  was  found  in  the  abdo- 
men. A  good-sized  staff  passed  easily  through  the  tube 
into  the  uterus.* 

Intermitting  ovarian  hydroceles  are  very  rare. 

Ovariafi  hyd?'oceks  and  tubal  pregna7tcy.—T\)Ltse  two 
conditions  have  an  interesting  relation  to  each  other.  It 
is  discussed  in  chapter  xxix. 

ZzV^r^/«r^.— Richard  :  Memoires  de  la  Societe  de  Chirurgie  de 
Pa7-is,  \o\.  iii.  p.  I2i,  1853;  Griffith:  "  Tubo-Ovarian  Cysts"; 
Trails.  Obstet.  Soc,  London,  vol.  xxix,  p.  273. 

*  Diseases  of  lVo?ne/?,  p.  324;   1873. 


123 


CHAPTER  XIL 

SECONDARY     CHANGES     IN     OVARIAN     TUMOURS. 
INFLAMMATION,       SUPPURATION,       AND       ADHESIONS. 

Ovarian    tumours    are    liable    to    secondary    changes, 
several   of  which  are  important  clinicall}',   as  they  en- 
danger the  life  of  the  patient.     The  chief  of  these  are  : — 
Inflammation  and  suppuration. 
Axial  rotation. 
Rupture  of  the  cyst. 

This  chapter  will  be  devoted  to  the  consideration  of 
the  changes  induced  by  inflammation  of  the  cyst. 

All  who  have  performed,  or  assisted  at,  the  operation 
of  ovariotomy  must  have  been  struck  by  the  fact  that  at 
times  a  large  C3'st  holding  two  or  more  gallons  of  fluid 
will  be  withdrawn,  its  external  surface  being  smooth  and 
glistening  like  the  healthy  peritoneum,  whilst  in  another 
and  much  smaller  specimen  the  cyst  walls  are  adherent 
to  almost  every  organ  in  the  neighbourhood,  so  that  when 
its  removal  is  at  last  accomplished  the  surface  of  the 
cyst  is  covered  with  villous  tufts  of  new  tissue,  and 
resembles  in  outward  appearance  the  shaggy  sides  of  a 
Skye  terrier.  Such  adhesions  arise  from  the  organisation 
of  inflammatory  exudation. 

The  tissues  of  ovarian  tumours  may  inflame  from 
several  causes  :  at  first  glance  it  seems  somewhat  difficult 
to  understand  how  ovarian  cysts  should  become  inflamed, 
enclosed  as  they  are  in  air-tight  cavities,  and  having  no 
communication  with  other  organs.  A  little  reflection 
soon    reveals  several  sources  of  infection  ;  of  these  the 


124  Diseases  of  the  Ovaries. 

principal  are  : — The  intestinal  canal,  the  urinary  bladder, 
the  Fallopian  tube,  and  in  some  cases  the  accidental 
admission  of  air  by  tapping. 

Speaking  generally,  it  is  not  the  large  cysts  which 
rise  up  out  of  the  pelvis  and  occupy  the  greater  part 
of  the  abdomen  that  become  inflamed  to  any  serious 
extent,  but  tumours  of  moderate  size,  which  remain 
wedged  in  the  pelvis,  and  especially  cysts  with  dermoid 
contents. 

The  chief  channel  by  which  infection  gains  access  to 
these  cysts  is  the  Fallopia?!  tube.  The  part  played  by 
this  duct  in  producing  inflammation  of  the  ovary  and 
pelvic  peritoneum  has  been  adequately  recognised  by 
many  in  recent  years,  but  no  writer  has  thought  fit  to 
discuss  its  relation  to  inflammation  of  ovarian  tumours, 
yet  every  surgeon  of  experience  will  agree  in  the  opinion 
that  of  all  adhesions  encountered  in  ovariotomy,  the 
densest  and  most  difficult  are  those  which  occupy  the 
pelvis. 

Again,  the  opinion  that  the  Fallopian  tube  is  the 
channel  by  which  the  infecting  material  gains  access  to 
the  walls  of  the  tumour  is  not  a  matter  of  inference,  but 
of  direct  observation,  for  an  examination  of  such  tumours 
will  often  reveal  the  fact  that  the  adhesions  are  most 
abundant  in  the  immediate  neighbourhood  of  the  ostium 
of  the  tube ;  and  an  examination  of  the  tube  will  bring  to 
light  evidence  of  existing,  recent,  or  past  salpingitis.  My 
attention  was  more  particularly  directed  to  this  matter  by 
the  following  case  : — 

A  woman  forty  years  of  age,  who  had  been  married 
many  years,  but  had  never  been  pregnant^  came  under 
my  care  with  symptoms  of  pelvic  tumour.  For  several 
years  she  had  suffered  from  a  vaginal  discharge.  On 
examination,  the  cervix  of  the  uterus  was  found  so  long 
as  to  protrude  at  the  genital  orifice,  and  there  was  no 


Salpingitis  and    Ovarian   Cysts. 


125 


difficulty  in  recognising  a  tumour  somewhat  larger  than 
an  orange  occupying  the  recto-vaginal  pouch.  This 
tumour  was  very  tender.  Rest  and  palliative  treatment 
led  to  no  improvement,  and  in  due  course  abdominal 
section  was  performed.  At  the  operation  a  dermoid 
cyst  as  big  as  an  orange  was  found  replacing  the  right 


OVARY. 


HAIR 


Fig.  54. — Ovarian  Dermoid  and  Pyosalpinx.     One-third  natural  size. 
The  tumour  was  fixed  by  dense  adhesions. 

ovary ;  it  was  intimately  adherent  to  the  broad  ligament 
and  pelvic  peritoneum ;  the  Fallopian  tube  was  converted 
into  a  large  pyosalpinx,  and  bound  to  the  tumour  by 
tough  adhesions  (Fig.  54).  On  slitting  up  the  tube  its 
walls  were  found  to  be  lined  by  velvety  granulation  tissue. 
The  left  Fallopian  tube  was  converted  into  a  retention 
cyst  as  big  as  a  ripe  fig. 

Since  making  the  above  observation,  many  specimens 
have  come  under  my  notice  in  which  by  dissection  and 


126 


Diseases  of  the  Ovaries. 


microscopical  examination  I  have  been  able  to  demon- 
strate the  co-existence  of  sub-acute  or  chronic  salpingitis 
and  adherent  ovarian  cysts,  especially  dermoids.  An  ad- 
herent ovarian  cyst  associated  with  salpingitis  is  sketched 
in  Fig.  55.  .  •        . 


Fig.  55. — Small  adherent  Ovarian  Cyst. 
The  tube  presented  good  evidence  of  chronic  salpingitis. 


Valuable  evidence  in  support  of  the  relation  between 
salpingitis  and  pelvic  adhesions  of  ovarian  tumours  is 
furnished  in  a  paper  published  by  Thornton,  entitled 
"  Three  Hundred  Additional  Cases  of  Ovariotomy."  On 
examining  the  meagre  details  of  each  case,  I  find  that  in 
one  hundred  and  two  cases  (between  274  and  376  in  the 
list)  there  are  eight  instances  in  which  hydrosalpinx  was 


Adhesions   of   the   Appendix.  127 

found  on  the  side  opposite  to  the  cyst,  and  in  two  patients 
hydrosalpinx  existed  on  each  side.  In  all  the  cases  but 
one  in  which  hydrosalpinx  was  present,  there  were  dense 
adhesions,  especially  in  the  pelvis.* 

Inflammation  of  the  cyst  wall,  set  up  by  infection 
conveyed  through  the  Fallopian  tube,  is  not  always 
restricted  to  the  immediate  neighbourhood  of  the  tube, 
but  may  extend  over  the  cyst,  and  lead  to  adhesions 
between  it  and  the  omentum,  intestines,  and  parietal 
peritoneum. 

On  the  other  hand,  the  intestines  may  be  the  source 
of  infection.  For  instance,  a  portion  of  the  small  intestine 
or  the  rectum  may  become  adherent  to  the  cyst  wall,  in 
consequence  of  inflammatory  changes  arising  in  the  gut 
itself.  The  adherent  piece  of  intestine  becomes  pressed 
upon  by  the  tumour,  the  wall  of  the  gut  thins,  and  allows 
the  intestinal  gases  to  diffuse,  and  cause  suppuration. 
Occasionally  the  walls  of  the  cyst  become  so  thin  that 
the  gas  enters  the  cavity  of  the  cyst,  sets  up  putrefaction, 
and  converts  it  into  a  huge  abscess  ;  not  rarely  commu- 
nication becomes  established  between  the  intestine  and 
the  interior  of  the  cyst,  whereby  its  contents  escape. 
This  condition  is  discussed  in  detail  in  chapter  xiv. 

An  important  mode  in  which  inflammation  of  the 
wall  of  an  ovarian  cyst  is  initiated  is  by  appendicitis. 

More  than  one  surgeon  has  noticed  that  the  vermi- 
form appendix  has  been  fixed  to  the  walls  of  a  cyst  by 
firm  adhesions,  but  no  one,  so  far  as  I  know,  has  urged 
that  the  appendix  in  many  of  these  was  the  source  of  the 
inflammation  which  led  to  the  adhesions. 

Doran,  in  his  admirable  observations  on  tumours  of 
the  ovary,  has  given  brief  descriptions  of  six  cases  in 
which  he  detected  adhesions  of  the  vermiform  appendix 

*  MedicO'Chir,  Trans.,  vol.   xx.  p.  41. 


128  Diseases  of  the  Ovaries. 

to  the  walls  of  an  ovarian  cyst.  He  writes  that  *'  adhe- 
sion of  the  vermiform  appendix  appears  almost  invariably 
associated  with  extensive  adhesions  between  the  tumour 
and  other  abdominal  structures,"  and  mentions  a  case 
which  occurred  in  a  woman,  aged  thirty-five  years, 
operated  upon  for  ovarian  cyst.  The  adhesions  were  so 
universal,  and  the  structures  adjacent  to  the  tumour  so 
altered  by  pathological  changes,  that  the  true  nature  of 
the  patient's  disease  could  not  be  determined  until  after 
death.  On  post  viorteni  examination  a  fused  double 
ovarian  cyst  was  recognised.  The  appendix  was  six 
inches  in  length,  and  strongly  adherent  to  the  cyst  wall ; 
three  inches  of  the  adherent  portion  could  not  be  sepa- 
rated. The  appendix  was  cut  from  the  tumour  and 
ligatured  ;  a  plug  of  solid  faeces  was  squeezed  out  of  it. 

My  first  ovariotomy  was  performed  upon  a  patient 
with  a  very  large  cyst  adherent  everywhere,  and  at  the 
operation  the  appendix  was  so  firmly  adherent  that  it  was 
cut  and  the  end  ligatured.  The  main  cyst  contained  two 
gallons  of  fcetid  pus.  Subsequent  dissection  showed  that 
I  had  to  deal  with  a  fused  double  ovarian  cyst. 

It  is  important  to  recognise  this  relation  of  the 
appendix  to  ovarian  tumours,  because  if  it  be  cut  through 
or  torn,  and  the  accident  not  recognised,  disaster  is  sure 
to  follow. 

Suppuration  of  ovarian  tumours  next  claims  attention. 
It  was  formerly  believed  that  this  was  almost  invariably 
associated  with  tapping  the  cyst  and  accidental  ad- 
mission of  air.  Although  suppuration  occasionally 
followed  the  tapping  in  large  cysts,  it  nevertheless  occurs 
independently  of  such  interference.  The  cases  which 
most  attract  attention  are  those  in  which  suppura- 
tion occurs  in  cysts  large  enough  to  rise  above  the  pelvic 
brim.  In  smaller  cysts,  low  down  in  the  pelvis,  especially 
dermoids,  suppuration  is  of  common  occurrence. 


SuppuRATJON  m  Ovarian   Cysts.  129 

Suppuration  in  ovarian  cysts  is,  in  most  cases,  due 
to  communication  with  neighbouring  viscera,  such  as 
intestines,  rectum,  bladder,  or  vagina. 

The  result  of  the  suppuration  is  to  set  up  almost 
universal  adhesions  to  surrounding  structures  ;  in  acute 
cases  severe  symptoms  arise,  and  unless  the  pus  find 
an  exit,  the  patient  die«.  Even  when  the  pus  finds  an 
outlet  the  patient  leads  a  miserable  existence,  becomes 
emaciated  by  the  prolonged  discharge,  and  dies  worn  out 
by  suffering. 

In  acitte  suppuration  of  a  large  ovarian  cyst  the 
symptoms  are  very  characteristic.  The  patient  presents 
the  usual  signs  of  an  ovarian  tumour,  but  there  are  pain 
and  tenderness  on  pressure ;  the  pulse  is  rapid  and  feeble, 
and  there  are  great  emaciation  and  exhaustion.  The 
temperature  is  at  first  high,  standing  at  100°  or  102°  in 
the  morning,  and  rising  to  103°  or  105°  in  the  evening. 
As  the  patients  become  more  and  more  exhausted  to- 
wards the  close  of  the  case  the  temperature  may  fall, 
and  has  been  recorded  as  low  as  95''.  This  low  tempera- 
ture has  been  observed  in  cases  where  the  pus  was 
unusually  offensive.  In  many  case:-  the  urine  contains 
albumen.  The  cyst  sometimes  contains  gas  :  under  such 
conditions  the  tumour  dulness  is  replaced  by  a  highly 
tympanitic  note. 

Suppurating  dermoid  cysts  of  the  ovary  are  by  no 
means  infrequent,  and,  like  other  forms  of  ovarian  cysts, 
when  inflamed  they  become  firmly  adherent  to  surround- 
ing structures.  They  may  burst  into  the  peritoneum,  or 
through  the  rectum,  bladder,  vagina,  or  even  through  the 
abdominal  wall,  near  Poupart's  ligament,  or  at  the  um- 
bihcus.  Records  of  a  large  number  of  cases  of  pelvic 
dermoids,  which  have  suppurated  and  discharged  through 
mucous  canals,  occur  in  medical  and  surgical  literature. 
In  some  the  fistula  which  forms  gives,  rise  to  very  little 

J 


130  Diseases  of  the  Ovaries. 

inconvenience,  but  when  the  cyst  communicates  with  the 
bladder  it  may  entail  the  greatest  misery — fragments  of 
bone,  teeth,  locks  of  hair,  and  sloughs  become  im- 
pacted in  the  urethra,  and  cystitis,  with  all  its  attendant 
evils,  is  the  almost  constant  accompaniment.  The  frag- 
ments of  tissue  retained  in  the  bladder  often  become 
covered  with  phosphatic  deposit. 

Several  instances  have  been  recorded  in  which  a  tooth 
has  formed  the  nucleus  of  a  vesical  calculus.  The  most 
convincing  case  of  this  nature  is  one  recorded  by  Black- 
man  :■ — * 

A  woman  thirty-six  years  of  age  had  been  married 
twelve  years,  and  remained  sterile.  At  the  age  of  twenty- 
one  she  suffered  from  pain,  and,  for  thirteen  months, 
amenorrhcea.  At  that  time  she  had  an  escape  of  air 
from  the  bladder.  For  years  she  suffered  from  irrita- 
bility of  the  bladder  and  the  escape  of  urine  from  the 
rectum.  At  the  age  of  twenty-six  a  phosphatic  calculus 
was  extracted,  having  a  tooth  for  its  nucleus.  A  year 
later  a  similar  one  was  removed.  At  the  age  of  thirty  a 
third  was  removed.  At  thirty -three  a  fourth  was  found 
fixed  in  an  opening  just  sufficient  to  admit  the  tip  of  the 
forefinger  at  the  upper  and  left  part  of  the  bladder.  After 
this  operation  urine  ceased  to  flow  from  the  rectum.  A 
few  months  later  hair,  encrusted  with  phosphates,  was 
passed,  and  there  was  reason  to  suspect  another  calculus. 
The  history  ceases  at  this  point. 

Sir  Benjamin  Brodie  has  recorded  a  case  in  which  two 
ovarian  teeth  and  a  fragment  of  bone  formed  the  nucleus 
of  a  vesical  calculus. 

An  extensive  study  of  the  clinical  reports  of  cases  in 
which  dermoids  have  suppurated  and  burst,  either  through 
the  abdominal  wall  or  into  mucous  canals,  shows  that 

*  American  Journal  oj  Medical  Sciences ^  January,  1869,  p.  49. 


Suppuration  in   Ovarian   Cysts.  131 

the  contents  of  the  cysts  have,  in  a  few  instances,  sloughed 
out,  and  the  sinus  closed,  but  in  the  majority  life  has 
been  rendered  a  burden,  death  being  induced  by  hectic, 
the  duration  of  the  case  varying  from  a  few  months  to 
several  years.  Occasionally  the  patients  lead  a  tolerably 
comfortable  existence,  even  in  those  cases  where  the 
cyst  communicates  with  the  bladder.  Such  patients 
are  annoyed  with  the  formation  of  concretions,  which 
require  removal  from  time  to  time,  but  eventually 
death  is  induced  as  a  consequence  of  renal  complica- 
tions.* 

A  case  full  of  interest,  in  demonstrating  the  relation 
between  suppurating  ovarian  cysts  and  the  intestine,  has 
been  recorded  by  Doran  : — f 

A  woman  twenty-six  years  of  age  was  suddenly 
seized  with  rigors  and  severe  abdominal  pain,  symptoms 
which  led  a  practitioner  to  regard  the  case  as  one 
of  typhoid  fever.  Fourteen  days  afterwards  Mr. 
Manser  was  consulted,  and  detected  an  ovarian  tumour, 
and  he  came  to  the  conclusion  that  the  high  temperature, 
100°  to  102°,  was  due  to  peritonitis  complicating  ovarian 
disease.  Eventually  she  came  under  Dr.  Bantock's  care, 
at  the  Samaritan  Hospital.  This  surgeon  removed  a 
suppurating  multilocular  tumour  of  the  left  ovary,  con- 
taining seven  pints  of  turbid  fluid.  The  tumour  was  very 
closely  adherent  behind  to  eight  or  ten  inches  of  the 
lower  part  of  the  ileum.  The  patient  died  on  the  eighth 
day  after  the  operation. 

At  the  post  mortein  examination  ulceration  was  de- 
tected in  the  ileum,  and  a  perforating  circular  ulcer,  with 
clean-cut  edges,  unassociated  with  Peyer's  patches,  was 

*  Herman's  paper,  "Suppurating  Dermoid  Cysts  of  the  Pelvis," 
contains  abstracts  of  many  interesting  cases.  ( Trans.  Obstet.  Soc, 
London,  vol.  xxvii.  p.  254.) 

•}•    Trans.  Path.  Soc,  vol.  xxx.  p.  298. 

J     2 


132 


Diseases  oe  the  Ovaries. 


found.     Perforation  was  commencing  in  several  neigh- 
bouring ulcers. 

Adlic$ioii«!i,  from  whatever  cause  arising,  are  a  source 
of  anxiety  to  the  operator  when  they  are  abundant.  A 
few  straggling  omental  adhesions  are  of  no  moment,  or 
a  few  fibrous  bands  connecting  the  cyst  to  the  anterior 


i^^^mi]  ' 


Fig.    56.— Portion   of  the  Wall  of  an  Ovarian  Cyst,  with  shaggy  Adhesions. 

(After  Doran.) 

abdominal  wall ;  but  when  tracts  of  the  small  intestine, 
or  colon,  are  firmly  united  to  the  cyst  wall  by  broad 
fibrous  bands,  or  the  tumour  is  fixed  to  the  pelvic  peri- 
toneum by  dense  adhesions,  the  task  of  removing  the 
tumour  is  very  anxious,  tedious,  and  occasionally  im- 
possible. 

The  mode  by  which  adhesions  arise  is  identical  with 
the  process  by  which  bands  arise  in  connection  with  the 


Adhesions,  133 

intestines.  The  peritoneum  becomes  inflamed,  and  the 
exudation  which  accompanies  that  process — the  so-called 
lymph  — organises,  and  undergoes  slow  conversion  into 
fibrous  tissue.  When  the  parts  united  by  this  material 
remain  in  apposition  during  the  process  of  organisation,  a 
sessile  adhesion  is  the  result.  If,  whilst  the  lymph  is 
recent  or  only  partially  organised,  movement  takes  place 
between  the  parts,  then  the  uniting  material  becomes 
stretched  into  broad  or  narrow  bands,  according  to  the 
amount  of  surface  involved.  Thus,  in  some  specimens 
the  cyst  when  removed  presents  a  shaggy  appearance 
(Fig.  56) ;  whilst  in  rarer  cases  the  organised  material  will 
form  a  spurious  capsule  over  a  large  portion  of  the  cyst 
wall.  Long  adhesions  are  usually  found  over  the  anterior 
wall  and  crown  of  a  cyst  ;  sessile  adhesions  are  most  fre- 
quent on  its  pelvic  aspect. 

Old-standing  adhesions  usually  contain  blood-vessels, 
and  these,  when  they  spring  from  intestine  or  omentum 
or  uterus,  are  of  large  size,  and  bleed  freely  when  de- 
tached. So  vascular  are  these  adhesions  that  in  some 
cases  in  which  the  pedicle  of  the  tumour  has  been 
destroyed  by  rotation,  or  dragging,  they  have  served  to 
keep  the  tumour  alive. 

Adhesions  to  the  pelvic  peritoneum  are  most  dreaded 
by  surgeons,  not  only  because  of  the  difficulty  in  reaching 
them,  but  also  on  account  of  their  relation  to  the  ihac 
arteries  and  veins,  the  ovarian  vessels  and  ureters  at  the 
brim  of  the  pelvis.  The  iHac  vessels  have  been  laid  bare 
in  separating  adhesions,  and  lacerated ;  the  inferior  vena 
cava  and  the  ureter  have  been  torn  through.  In  many 
cases  the  cyst  wall  has  been  found  so  intimately  united 
to  the  peritoneum  that  a  portion  of  it  has  been  left 
behind. 

It  used  to  be  the  practice  to  endeavour  to  determine 
the  existence  of  adhesions  before  advising  operation,  but 


134  Diseases  of  the  Ovaries. 

it  has  so  frequently  happened  that  when  adhesions  have 
been  suspected  the  surgeon  has  found  the  cyst  free,  and 
when  none  have  been  suspected  the  tumour  has  been 
universally  adherent,  that  it  is  not  always  easy  to  deter- 
mine whether  a  cyst  is  fixed  in  the  pelvis  by  adhe- 
sions, impacted,  or  situated  between  the  folds  of  the 
broad  ligament. 


135 


CHAPTER     XIII. 

AXIAL    ROTATION. 

Cysts  and  solid  tumours  arising  in  connection  with  the 
ovaries,  Fallopian  tubes,  and  uterus  occasionally  rotate 
on  their  axes  :  a  movement  which  leads  to  the  torsion  of 
those  structures  which  form  the  pedicle  of  the  tumour, 
and  gives  rise  to  changes  of  pathological  and  clinical 
importance. 

Axial  rotation  has  been  most  carefully  studied  in 
ovarian  and  parovarian  cysts.  Rokitansky  drew  attention 
to  its  occurrence  in  i860;  since  that  date  it  has  been 
studied  by  surgeons. 

Judging  from  the  many  recorded  cases,  it  would  seem 
that  twisted  pedicles  occur  in  about  ten  per  cent,  of  the 
cases  of  ovarian  and  parovarian  tumours. 

Concerning  the  cause  of  this  rotation  we  know  little. 
Various  explanations  have  been  advanced.  It  has  been 
attributed  to  the  alternate  distension  and  evacuation  of 
the  bladder  (Klob) ;  or  to  the  passage  of  faeces  through 
the  rectum  (Lawson  Tait) ;  to  sudden  movements,  such 
as  a  fall,  slip,  or  unusual  exertion  (Thornton).-  An  im- 
portant fact  to  remember  is  the  frequency  with  which 
this  accident  occurs  when  ovarian  cysts  complicate 
pregnancy.  In  fifty- seven  instances  of  axial  rotation 
recorded  by  Thornton,  fourteen  were  thus  associated  : 
that  is,  one-fourth  of  the  total  number. 

When  both  ovaries  are  cystic,  the  risk  of  twisting 
is  nearly  the  same  as  when  pregnancy  and  an  ovarian 
cyst  are  associated;    when  both  ovaries  are  cystic  and 


J 


6  Diseases  of  the  Oi'aries. 


pregnancy  ensues,  the  risk  of  axial  rotation  is  more  than 
doubled. 

The  torsion  may  occur  early  in  the  pregnancy  or  be 
delayed  till  delivery ;  in  many  of  the  cases  it  happened 
shortly  after  delivery  or  miscarriage. 

The  occurrence  of  acute  torsion  immediately  after 
delivery  is  doubtless  due  to  the  rapid  diminution  in  size 
of  the  uterus,  and  the  movement  which  this  organ,  as  it 
sinks  into  the  pelvis,  imparts  to  the  tumour. 

A  case  of  great  importance  in  this  relation  has  been 
recorded  by  Edwards: — * 

A  woman  twenty-four  years  of  age  had,  for  at  least  two 
years  previously,  an  ovarian  tumour  on  the  right  side.  The 
tumour  did  not  attract  much  attention  until  she  became 
pregnant,  in  the  early  part  of  the  year  i860.  In  October 
of  that  year  she  was  delivered  of  a  child  which  was 
scarcely  full-grown,  and  survived  its  birth  a  few  days. 
I7nmediately  after  the  bU'th  of  the  child  the  tumou?'  shifted 
over  to  the  7niddle  of  the  abdomen. 

On  August  5th,  1 86 1,  this  woman  was  again  delivered 
of  a  child  at  the  seventh  month ;  it  lived  a  few  hours. 
After  the  birth  of  the  child  the  tumour  was  found  in  the 
middle  line  of  the  abdomen.  Two  days  later  collapse 
occurred,  and  the  patient  died  on  August  8th. 

At  the  post  ino7'tem  examination  the  pedicle  of  the 
cyst  was  found  twisted  one  turn  and  a  half;  it  contained 
eight  pints  of  blood-stained  fluid.  The  ovary  was  found 
on  the  surface  of  the  cyst ;  it  was  therefore  of  parovarian 
origin. 

Rotation  of  a  cyst  in  the  early  stages  of  pregnancy  is 
probably  due  to  the  gradual  enlargement  of  the  uterus 
displacing  the  tumour  upwards,  and  as  the  pressure  is 
exerted  upon   one  side  of  the  cyst,  it  would  be  in  a 

"'^  La/iccf,  1861,  vol.  ii.  p.  336. 


TuE   Effects   of    Torsion.  137 

favourable  position  to  impart  a  rotatory  motion  to  a  non- 
adherent cyst.  The  ainouiit  of  rotation  varies  greatly  :  in 
some  cases  the  cyst  has  only  turned  through  half  a  circle, 
in  others  as  many  as  twelve  complete  twists  have  been 
counted  (Halliday  Croom).  The  direction  of  the  rota- 
tion may  be  from  right  to  left,  or  vice  ve7'sa,  but  cysts 
exhibit  a  stronger  tendency  to  rotate  towards  the  middle 
line  rather  than  from  it.  Tumours  of  the  right  and  left 
side  are  equally  liable  to  rotate. 

The  effect  of  torsion  on  the  circulation  depends  on 
the  tightness  of  the  twist,  and  this  varies  with  the  thick- 
ness of  the  pedicle.  The  vessels  in  a  long  thin  pedicle 
would  suffer  obstruction  quicker  than  those  in  a  short 
and  thick  one.  When  a  pedicle  is  torsioned  the  thin- 
walled  veins  become  compressed,  whilst  the  more  resilient 
arteries  continue  to  convey  blood  to  the  cyst.  The 
result  is  severe  venous  engorgement,  and  this  leads  to 
extravasation  of  blood  into  the  cyst  wall ;  in  many  cases 
the  veins  rupture,  and  haemorrhage  takes  place  into  the 
cavity  of  the  cyst.  The  haemorrhage  may  be  so  profuse 
as  to  cause  profound  anaemia,  and  even  death.  Sir 
Spencer  Wells  "^  relates  a  case  which  occurred  at  the 
Hospital  for  Incurables,  Putney.  The  patient  had  been 
found  dead  by  the  bedside.  On  opening  the  abdomen 
a  large  ovarian  cyst  was  found,  which  contained  five 
pounds  of  blood-clot :  the  bleeding  was  secondary  to  a 
twisted  pedicle. 

This  surgeon  has  briefly  recorded  a  more  exceptional 
case : — 

He  went  once  to  operate  on  a  lady  who  had  died 
unexpectedly  two  hours  before  his  arrival.  "The  post 
mortem  examination  showed  that  death  was  due  to  a  very 
large  extravasation  of  blood,  first  into  an  ovarian  cyst, 

*  Ovarian  and  Uterine  Tiano2irs,  p.  64  ;    1882. 


138  Diseases  of  the  Ovaries. 

and  then,  after  its  bursting,  into  the  abdominal  cavity, 
evidently  the  consequence  of  a  complete  twist  of  the 
pedicle  by  the  rotation  of  a  non-adherent  cyst." 

When  the  venous  circulation  is  completely  arrested 
in  consequence  of  torsion,  the  appearance  of  the  cyst  is 
very  striking  and  characteristic.  On  opening  the  ab- 
domen during  life,  instead  of  the  cyst  presenting  the 
familiar  white  glistening  appearance,  it  has  a  deep 
dark  lustreless  hue,  which  is  most  intense  near  its 
attachment  to  the  pedicle.  In  milder  degrees  of  torsion 
the  change  in  colour  only  affects  the  base  of  the  tumour. 
The  pedicle  on  the  distal  side  of  the  twist  presents  the 
same  dark  hue,  but  on  the  uterine  side  it  is,  as  a  rule,  of 
natural  tint.  The  contrast  of  colour  in  the  two  parts  of 
the  pedicle  is  very  striking.  The  walls  of  the  cyst  are 
thick  and  succulent ;  the  fluid  contained  in  the  cavity,  or 
in  the  loculi  if  multilocular,  may  be  of  a  chocolate  or  of 
a  dark  red  colour. 

When  such  a  cyst  is  removed  from  the  body  and  the 
blood  allowed  to  drain  away,  or  is  washed  away  by  a 
gentle  stream  of  water,  the  tissues  will  resume  their 
natural  colour.  This  should  be  remembered,  because 
some  writers  have  attributed  this  dark  colour  to  gangrene 
of  the  cyst.  This  is  erroneous ;  gangrene  of  an  ovarian 
cyst  is  a  rare  event,  and  can  only  take  place  when,  air  is 
admitted  from  without,  as  during  the  operation  of  tapping, 
or  when  intestinal  gases  gain  entrance. 

The  usual  effects  of  acute  torsion  of  the  pedicle  are 
passive  congestion,  thrombosis,  and  extravasation  of 
blood  into  the  tissues  of  the  tumour  and  necrosis. 

Necrosis  is  localised  death,  in  contrast  to  death  of  the 
organism  as  a  whole,  or  "somatic  death." 

Moist  ga?2grene  is  necrosis  followed  by  decomposition  and 
putrefaction  of  the  dead  tissues.  When  soft  parts  necrose 
in  situations  where  they  are  accessible  to  putrefactive 


Gangrenous  Or.iRiAx  Cvsts.  139 

organisms,  such  as  the  exterior  of  the  body,  the  lungs,  or  the 
intestinal  tract,  decomposition  rapidly  ensues,  especially  if 
the  parts  contain  much  blood.  In  the  case  of  ovarian 
tumours  with  twisted  pedicles,  not  in  communication  with 
the  outer  air  directly  or  indirectly,  putrefactive  organisms 
can  rarely  gain  access  to  them  to  cause  decomposition. 

It  is  therefore  erroneous  to  describe  as  gangrene 
the  changes  observed  in  cysts  with  torsioned  pedicles. 
This  is  further  illustrated  by  the  circumstance  that  small 
ovarian  tumours  may  be  completely  twisted  from  their 
pedicles,  and  subsequently  shrink.  Were  the  changes 
in  the  cyst  gangrenous  in  character,  general  infection  of 
the  peritoneum  and  death  would  be  the  inevitable 
consequences, 

A  probable  case  of  gangrene  of  an  ovarian  cyst  in 
association  with  a  twisted  pedicle  has  been  put  on  record 
by  Thornton,*  but  the  accident  was  complicated  by 
tapping.  The  facts  of  the  case  are  briefly  these  : — A 
married  woman  twenty-eight  years  of  age  was  admitted  into 
the  Samaritan  Hospital  (1S75)  with  an  ovarian  tumour. 
She  was  \\  months  pregnant.  On  October  19th  she  was 
tapped,  and  ten  pints  of  fluid  removed,  but  some  masses 
of  smaller  cysts  were  left  behind.  Next  day  she  had 
headache,  temperature  100°,  and  a  rapid  pulse,  and  this 
condition  continued  for  a  few  days.  On  October  26th 
the  patient,  after  turning  rather  quickly  in  bed,  was 
seized  with  extreme  abdominal  pain ;  her  face  became 
dusky,  the  pulse  was  feeble  and  rapid,  and  the  tempera- 
ture began  to  fall.  Next  morning  the  patient's  condition 
was  much  worse,  and  it  was  decided  to  open  the  ab- 
domen. The  tumour  was  found  behind  the  uterus.  It 
"was  mottled  black  and  white,  and  dull,  and  coated  with 
lymph  in  patches,  evidently  in  a  partially  gangrenous 

*   Trans.  Path.  Soc,  vol,  xxvii.  p.  212. 


T40  Diseases  oe  the  OrAKiES. 

condition  " ;  the  pedicle  was  short,  and  twisted  three  and 
a  half  times  upon  itself.  The  patient  died  sixteen  hours 
after  the  operation. 

Even  in  this  case  the  evidence  that  the  cyst  was 
gangrenous  is  not  of  the  most  satisfactory  kind. 

A  perusal  of  the  records  of  cases  described  as  gan- 
grene indicates  that  the  reporters  have  regarded  the  deep 
livid  hue  of  such  cysts  as  evidence  of  gangrene,  and  others 
have  confounded  suppurating  and  gangrenous  cysts. 

Rotation  of  an  ovarian  cyst  when  it  gives  rise  to  such 
severe  changes  as  have  just  been  considered  may  be 
described  as  acute  torsion.  It  frequently  happens  that 
during  the  performance  of  ovariotomy  a  thick  pedicle  is 
found  twisted  through  half,  or  even  a  complete  circle, 
without  producing  an  appreciable  effect  upon  the  tumour. 
In  others,  torsion  takes  place  so  gradually  yet  so  com- 
pletely that  the  pedicle  is  twisted  like  a  rope,  and  not 
infrequently  the  pedicle  breaks  and  the  tumour  becomes 
detached  from  its  uterine  connections.  To  this  variety 
the  term  slo2V  or  chronic  torsion  may  be  applied.  Its 
effects  are  not  less  interesting  than  those  which  follow 
the  acute  variety.  When  rotation  occurs  slowly  the  walls 
of  the  cyst  inflame,  and  adhesions  are  established  between 
the  cyst  and  the  omentum,  or  the  parietal  peritoneum ; 
such  adhesions  become  vascular,  and  maintain  the  vitahty 
of  the  cyst  wall  after  circulation  is  arrested  through  the 
pedicle.  Such  adhesions  prevent  atrophy  of  the  cyst, 
but  are  probably  not  sufficient  to  allow  of  it  continuing 
to  increase  in  size.  Cysts  have  been  observed  in  all 
stages  of  transplantation.  The  best  example  which  I 
have  had  an  opportunity  of  observing  of  this  kind  of 
adhesion  was  a  cyst  removed  by  Greig  Smith ;  it  was 
adherent  to  the  omentum,  but  a  thin  frail  band  of  tissue 
connected  the  tumour  with  the  right  angle  of  the 
uterus.     The    tumour   was   of  the  size  of  a  melon  and 


Acute  Torsion. 


141 


multilociilar  ;  one  loculus  contained  a  patch  of  piliferous 
skin.     The  thin  frail  ligament  which  indicated  the  uterine 


Fig-    57- — Ovarian   Cyst    which  had  become   detached   from   its    Uterine   con- 
nections, probably  by  torsion. 


attachment  of  the  tumour  was  connected  with  the  outer 
half  of  the  Fallopian  tube,  which  formed  a  conspicuous 
object  on  the  cyst  wall  (Fig.  57). 

It  is  a  fact,  not  without  interest,  that  acnfe  forsio?i  is 


142  Diseases  of  the  Ovaries. 

more  frequently  seen  in  tumours  of  medium  size ; 
acute  torsion  occurs  in  small  cysts,  but  it  is  the  small 
tumours,  especially  dermoids,  in  which  slow  torsion  iTsk^s 
place.  The  tumours  in  which  complete  detachment 
takes  place,  accompanied  by  transplantation,  are  in  the 
majority  of  instances  dermoids. 

Axial  rotation,  acute  and  chronic,  occurs  in  all  kinds 
of  ovarian  tumours.  Its  frequency  in  dermoids  has  been 
mentioned;  twisted  pedicles  have  been  reported  in 
multilocular  tumours,  in  sarcomata,  and  parovarian  cysts. 
It  occurs  at  all  ages.  Thornton  has  observed  it  as 
early  as  the  thirteenth,  and  Bantock  at  the  fifteenth  year. 
Potter  has  recorded  an  example  in  an  old  woman  of 
eighty-three  years.  The  rotation  in  this  case  did  not 
give  rise  to  trouble. 

The  frequency  with  which  axial  rotation  occurs  when 
an  ovarian  tumour  and  pregnancy  co-exist  has  been 
mentioned  ;  it  is  quite  as  frequent  when  ovarian  cysts 
are  associated  with  uterine  myomata.  Small  tumours 
probably  rotate  more  easily  than  large  ones,  but  the 
larger  the  cyst  the  more  severe  are  the  effects.  The 
greater  proportion  of  detached  ovarian  tumours  are  of 
small  size.  In  nearly  all  reported  cases  the  completely 
detached  tumours  have  been  oophoritic ;  but  an  unmis- 
takable case  of  separated  parovarian  cyst  is  figured  on 
page  109. 

It  must  not  be  forgotten  that  twisted  pedicles  are  met 
with  in  pedunculated  tumours  growing  in  connection  with 
other  organs. 

The  symptoms  of  acute  rotation  of  an  ovarian  cyst 
are  often  so  characteristic  as  to  lead  to  a  correct  diagnosis. 
When  a  woman  complains  of  sudden  and  violent  pain  in 
the  abdomen,  accompanied  with  vomiting,  and  she  is 
known  to  have  an  ovarian  tumour,  or  she  presents  herself 
for  the   first   time   to  the    surgeon  and    these    signs  are 


Symptoms  of  Rotation.  143 

associated  with  an  abdominal  swelling,  the  physical  signs 
of  which  are  indicative  of  an  ovarian  tumour,  axial  rota- 
tion should  be  suspected.  Should  the  patient  possess 
a  gravid  uterus  as  well  as  an  ovarian  cyst,  it  is  even  more 
probable  that  rotation  has  occurred ;  or  if  she  have  an 
ovarian  tumour  and  has  been  recently  delivered,  this  is 
an  additional  reason  for  suspecting  that  the  symptoms 
arise  from  a  twisted  pedicle.  The  first  case  which 
occurred  in  my  own  practice  was  instructive.  The 
patient  was  a  very  stout  woman,  about  forty  years  of  age, 
married,  but  had  never  been  pregnant.  She  was  suddenly 
seized  whilst  getting  out  of  bed  with  severe  pain  in  the 
right  side,  near  the  last  rib.  Her  medical  attendant  was 
summoned,  and  he  detected  a  tumour — probably  a  uterine 
fibroid — blocking  up  the  pelvis.  A  movable  tumour  could 
be  felt  in  the  right  iliac  and  lumbar  region^  manipulation 
of  which  caused  great  pain.  The  symptoms  indicated 
that  the  tumour  in  the  right  side  was  probably  an  ovarian 
tumour  w^hich  had  rotated ;  the  mass  in  the  pehis  was 
distinct  from  the  tumour  on  the  right  side.  The  woman 
was  admitted  into  the  ^Middlesex  Hospital,  and  the 
symptoms  continuing,  I  opened  the  abdomen,  and  found 
on  the  right  side  a  muldlocular  ovarian  tumour  as  large 
as  a  cocoa-nut ;  the  pedicle  was  twnsted  one  turn  and  a 
half.  The  tumour  w^as  engorged  with  blood  :  during 
the  manipulation  necessary  to  remove  the  tumour  the 
largest  loculus  ruptured.  The  tumour  on  the  left  side 
was  a  multilocular  cyst  as  large  as  an  orange  wedged 
tightly  in  the  recto-vaginal  pouch.  The  woman  made  a 
rapid  recovery. 

Lawson  Tait  points  out  that  in  some  of  these  cases 
the  abdomen  undergoes  a  very  rapid  and  unusual 
increase  in  size  a  few  days  before,  or  coincident  with,  the 
access  of  violent  pain. 

It  is  very  important  to  be  thoroughly  alive  to  the 


144  Diseases  of  the  Oi'aries. 

possibility  of  this  complication  arising  in  a  woman  known 
to  have  an  ovarian  tumour^  for  in  very  acute  rotation  the 
patient's  life  depends  on  prompt  action.  This  is  admir- 
ably illustrated  by  the  case  reported  by  Dr.  AViltshire,* 
which  has  since  become  classical  as  the  first  instance  in 
which  ovariotomy  was  performed  for  acute  symptoms 
caused  by  axial  rotation.  The  patient  was  a  woman 
fifty  years  of  age,  suffering  from  a  very  large  ovarian  cyst, 
which  had  been  known  to  exist  for  some  years.  A  few 
days  before  Dr.  Wiltshire  saw  her  she  was  seized,  after 
some  unusual  exertion,  with  acute  pain,  tenderness,  and 
swelling  of  the  tumour,  accompanied  by  incessant  vomit- 
ing. The  pulse  was  feeble  (105),  the  extremities  cold, 
and  the  urine  small  in  amount.  Stimulants  were  freely 
administered.  Next  day  (May  4th,  1868),  after  success- 
fully overcoming  the  prejudices  of  the  practitioner  in 
charge  of  the  case  and  Dr.  Murray,  the  abdomen  was 
opened  by  Dr.  Wiltshire.  The  tumour  presented  the 
appearance  of  a  strangulated  pile.  There  were  no  ad- 
hesions. When  the  cyst  was  punctured  a  gallon  of 
venous  blood  flowed  through  the  cannula.  The  pedicle 
was  tied  in  the  usual  way,  but  on  cutting  away  the 
tumour  the  ligature  slipped.  The  pedicle  was  so  rotten 
that  in  order  to  arrest  the  haemorrhage  it  was  necessary 
to  transfix  "the  right  half  of  the  body  of  the  uterus," 
and  tie  it  with  a  stout  silk  ligature.  The  patient  made 
an  admirable  and  uninterrupted  recovery. 

The  case  was  a  typical  example  of  the  effects  of  axial 
rotation,  but  the  amount  of  twisting  v;as  not  noted. 
"  Mr.  Spencer  Wells  suggested  the  source  of  the  blood 
was  the  twisting  of  the  cyst  upon  its  pedicle ;  "  and  Dr. 
Wiltshire  writes:  "This  explanation  occurred  to  me  at 
the  time  of  the  operation,  for  I  noticed  that  the  position 

*   Trans,  Path.  Soc,  Vol.  xix,  p.  295  ;  1868. 


Treatment  of  Rotated  Tumours.         145 

of  the  tumour  was  altered  after  tapping/'  The  case  is  of 
great  interest,  as  marking  a  distinct  advance  in  our 
method  of  deahng  with  this  accident. 

In  many  cases  axial  rotation  can  be  and  is  correctly 
diagnosed ;  often  the  accident  is  suspected  when  in 
reality  it  is  imitated  by  other  conditions.  This  is  more 
especially  likely  to  happen  when  a  gravid  Fallopian 
tube  ruptures.  The  two  conditions  often  simulate  each 
other.  The  differential  diagnosis  will  be  considered  when 
dealing  with  tubal  pregnancy. 

The  importance  of  recognising  the  symptoms  caused 
by  the  rotation  of  an  ovarian  tumour,  and  the  difficulty 
which  may  beset  the  interpretation,  are  well  set  forth  in  the 
following  instructive  case,  described  by  Lawson  Tait : — 

He  was  called  (1868)  to  see  in  consultation  a  woman 
forty-eight  years  of  age  with  a  small  strangulated  femoral 
hernia.  This  was  relieved  by  herniotomy,  and  the  acute 
symptoms  subsided.  Two  days  later  the  abdomen  was 
tympanitic,  temperature  101°,  face  dusky  and  anxious. 
Four  days  after  the  operation  she  died. 

At  the /(?j"/ w^/'/^w  examination  a  small  ovarian  cyst 
was  found  lying  in  the  pelvis ;  it  had  rotated,  and  the 
pedicle  had  been  tightly  twisted  through  four  and  a  half 
revolutions. 

In  the  slow  or  chronic  variety  of  axial  rotation  the 
symptoms  are  not  so  severe  as  to  enable  a  diagnosis  of 
the  condition  to  be  made.  Doran  is  the  only  writer  who 
has  suggested  that  "  dull  constant  abdominal  pains  in 
a  patient  who  keeps  in  good  health  and  bears  a  cystic 
tumour  that  increases  but  little  or  not  at  all  in  the  course 
of  many  months  or  years  is  a  suspicious  symptom." 

The  treatment  of  a  case  of  ovarian  tumour  in  which 
twisting  of  the  pedicle  is  suspected  admits  of  no 
question  :  it  is  immediate  ovariotomy ;  and  some  of  the 
most  brilliant  results   in    abdominal  surgery  have  been 

K 


146  Diseases  oi'   the  OrARiES. 

obtained  in  operations  undertaken  for  this  condition. 
The  prognosis  is  very  good,  especially  when  adhesions 
are  absent,  or  sHght  and  few  in  number.  The  pedicle 
rarely  causes  trouble,  as  it  is  already  narrowed  by  the 
rotation,  and  in  many  cases  the  vessels  have  become 
torsioned. 

Literature.  —  Rokitansky  :  "  Ueber  der  Strangulation  von 
Ovarial-tumoren  durch  Achsendrehung,"  Zeiisch.  der  K.  K,  Gcscll- 
schaft  der  A'erzte  in  Wien,  1865  ;  Lawson  Tait  :  Diseases  of  the 
Ovaries,  p.  295,  4th  ed.,  1883  ;  Doran  :  Tiunoicrs,  of  the  Ovaries, 
p.  118;  Turner:  Edin.  Med.  Jotirnal,  1860-61,  vol.  vi.  p.  698; 
Thornton:  International  Jownal  of  Med.  Science,  1888,  p.  357  ; 
Barnes,  Diseases  of  Women,  p.  336,  1873,  collected  together  the 
chief  references  up  to  that  date,  and  adds  some  interesting  cases  ; 
The  Transactions  of  the  Obstetrical  Society,  London,  vol.  xxii. , 
1880,  contains  a  report  of  an  excellent  discussion  on  axial  rotation 
of  ovarian  tumours  ;  Kiistner:   Centralblatt  fiir  Gyn.,  1 891. 


147 


CHAPTER  XIV. 

PRESSURE      EFFECTS. 

The  pressure  effects  to  be  studied  in  connection  with 
ovarian  cysts  are  of  two  kinds  : — The  effects  upon  the 
cyst  itself,  and  the  mischief  produced  upon  adjacent 
organs. 

On  examining  a  thin-walled  oophoritic,  or  a  parovarian 
cyst,  many  must  have  wondered,  considering  the  great 
tension  of  the  i^arts,  how  it  continued  to  grow  under 
such  conditions,  and  wnth  what  slight  force  it  could  be 
ruptured.  Indeed,  so  thin  are  the  walls  of  these  cysts 
in  many  places  that  manipulation  during  their  removal 
often  causes  them  to  burst. 

Rupture  of  ovarian  cysts  is  sometimes  occasioned 
by  violence ;  sJ)onta?ieous  riipiiire'x^  a  consequence  of  change 
in  the  cyst  wall  due  to  gradual  thinning,  the  result  of 
continual  pressure  ;  in  some  cases  it  is  caused  by  venous 
congestion,  secondary  to  rotation  of  the  cyst  producing 
torsion  of  the  pedicle.  Before  describing  the  various 
forms  of  rupture,  some  attention  must  be  devoted  to 
what  is  called  leakage.  An  examination  of  the  walls  of 
many  oophoritic  cysts  reveals  the  fact  that  they  are 
not  of  uniform  thickness ;  in  some  parts  the  thinner 
portions  project  as  rounded  prominences.  These  pro- 
jecting and  thin  portions  frequently  correspond  to  the 
so-called  secondary  cysts ;  it  is  these  thin  cysts  which  so 
frequently  rupture  during  the  removal  of  a  multilocular 
tumour;  there  is  good  evidence  to  lead  us  to  believe 
that    in    the    ordinary    course    of     events    such    cysts 

K    2 


148  DiSEASE-i    OF    THE    Ol' ARIES. 

occasionally  burst  into  the  peritoneal  cavity,  and  cause 
no  harm. 

Secondary  cysts  also  rupture  into  the  main  cavity  of 
the  tumour.  On  examining  the  interior  of  a  cyst  in 
which  this  has  occurred,  the  ruptured  cyst  is  represented 
as  a  more  or  less  shallow  recess  in  the  wall  of  the  main 
cyst ;  in  course  of  time  it  shrinks,  and  gradually  suffers 
effacement.  Soon  after  rupture  the  margins  of  the  burst 
cyst  become  thick  and  rounded,  and  as  the  cyst  wall 
shrinks  the  recess  resembles  very  closely  the  fossa  ovalis, 
and.  its  rounded  edge  the  annulus  ovalis,  on  the  wall  of 
the  right  auricular  cavity  of  the  heart.  As  the  edge 
contracts  the  recess  becomes  obliterated,  and  its  position 
indicated  by  a  thick  radiating  patch  of  cicatricial  tissue. 
When  small  loculi — or  secondary  cysts,  as  they  are  fre- 
quently called — are  situated  near  the  periphery  of  a  large 
cyst,  they  produce  absorption  as  the  result  of  continued 
pressure,  and  at  last  form  prominences  on  its  exterior. 
As  a  rule,  only  a  few  of  these  projections  are  present, 
but  occasionally  they  are  so  numerous  as  to  give  the  cyst 
an  embossed  appearance.  It  has  already  been  mentioned 
that  cysts,  originally  multilocular,  may  become  unilocular 
in  consequence  of  the  septa  between  the  various  cysts 
undergoing  atrophy.  An  intermediate  stage  of  this 
process  is  shown  in  Fig.  58  ;  in  this  specimen  two  cysts 
of  equal  size  have  been  growing  side  by  side,  persistent 
pressure  has  led  to  perforation  of  the  septum ;  this  con- 
verts the  dividing  wall  into  a  diaphragm  with  a  central 
perforation.  As  the  cyst  grows  the  orifice  increases  in 
size,  and  the  septum  gradually  atrophies,  leaving,  perhaps, 
a  ridge  on  the  inner  wall  of  the  cyst. 

The  mode  by  which  two  cysts  fuse  together  in  one 
ovary  illustrates  the  mode  by  which  cysts  originating  in 
opposite  ovaries  fuse  and  communicate  so  as  to  form 
one  cyst,  or  '-fused  double  ovarian   cysts,"  as  they  are 


Rupture  of  Oi'arian  Cysts. 


149 


called.  Such  conditions  are,  fortunately,  not  common, 
for  they  greatly  embarrass  the  surgeon.  The  identification 
of  the  condition  depends  on  the  recognition  of  two  true 


ACCESSORY   OSTIUM 


TULE 


Fig.  58. — Oophoritic  Cyst  with  a  perforated  Septum,  s,  between  its  two  Loculi. 


pedicles.     One  of  the  pedicles   may  be  mistaken  for  a 
dense  adhesion. 

When  the  wall  of  a  secondary  cyst  is  very  thin,  or  the 
parietes  of  an  unilocular  cyst  become  very  attenuated  ; 
there  is  reason  to  believe  that  transudation  takes  place 
into  the  peritoneal  cavity,  the  fluid  being  slowly  absorbed. 
This  gradual  leakage  causes  no  ill  effects  to  the  patient, 


150  D/SKASES    OF    THI-:    Ol'AKIES. 

and  the  presence  of  even  a  large  quantity  of  ovarian 
fluid  is  tolerated  by  the  peritoneum.  An  interesting  and 
striking  instance  of  this  has  been  recorded  by  W.  A. 
Meredith :— * 

A  single  woman,  forty-seven  years  of  age,  had  suffered 
from  abdominal  enlargement  ten  years.  She  came  unde 
observation  August,  1871.  An  ovarian  tumour  was 
diagnosed  and  tapped,  twenty  pints  of  fluid  being  with- 
drawn. The  cyst  re-filled  in  four  months.  "After  suffering 
a  smart  attack  of  pain  near  the  seat  of  the  tapping 
puncture,  she  noticed  one  day  a  sudden  alteration  in  the 
shape  of  the  tumour,  and  within  twenty-four  hours  began 
passing  large  quantities  of  clear  urine.  This  state  of 
diuresis  persisted  for  four  or  five  days,  at  the  end  of 
which  time  all  traces  of  the  abdominal  swelling  had 
disappeared."  This  re-filling  of  the  cyst,  followed  by 
spontaneous  rupture  and  removal  of  the  extravasated 
fluid  by  diuresis,  recurred  with  remarkable  regularity 
three  or  four  times  in  the  course  of  each  year.  On  one 
occasion  she  was  tapped  by  a  country  doctor,  who  drew 
off  a  ''  pailful  of  clear  fluid." 

In  September,  1S79,  when  she  presented  herself  at 
the  Samaritan  Hospital,  no  abdominal  tumour  could  be 
detected ;  she  returned  in  two  months,  and  "  the  ab- 
domen was  found  uniformly  distended  by  a  tense  dis- 
tinctly fluctuating  tumour," 

This  cyst,  which  had  ruptured  thirty-four  times  during 
a  period  of  nine  years,  was  removed  December  4,  1879. 
The  only  adhesions  present  were  a  few  filamentous  bands 
about  the  site  of  the  tapping  puncture.  The  cyst  con- 
tained twenty-one  pints  of  fluid.  It  had  one  large  cavity, 
with  a  group  of  secondary  cysts  growing  on  its  inner 
wall ;    "  the   remains   of   the    ovary,    together   with    the 

*    Tra?is,  Path,  Soc,  vol.  xxxi.  p.  i8o. 


S/CNS  OF  A  Ruptured  Cyst.  151 

adherent  Fallopian  tube,  are  seen  on  its  outer  surface." 
This  is  sufficient  to  show  that  it  was  a  parovarian  cyst. 
Numerous  recesses  and  cicatrices  were  detected  on  the 
inner  wall  of  the  cyst. 

It  is  remarkable  that  during  all  the  years  the  patient 
had  this  tumour  "she  was  never  once  incapacitated  for  a 
single  day  for  the  performance  of  her  ordinary  duties  as 
a  housemaid." 

The  history  of  this  extraordinary  case  illustrates  ad- 
mirably the  clinical  signs  of  so-called  spontaneous  rupture 
of  a  large  unilocular  cyst : — 

1.  Sudden  accession  of  pain,  accompanied  by  altera- 

tion in  the  shape  of  the  tumour. 

2.  Subsequent  profuse  diuresis. 

3.  Gradual    re-accumulation    of    the    fluid    in    the 

cyst. 

This  case  demonstrates  the  rapidity  with  which  large 
quantities  of  fluid  collect  in  ovarian  and  parovarian  cysts 
after  rupture.  The  following  account  of  a  large  dried 
ovarian  cyst  preserved  in  the  museum  of  the  Royal  Col- 
lege of  Surgeons  is  also  significant  in  this  respect : — - 

The  patient  was  twenty-seven  years  old  when  the 
disease  commenced,  after  a  miscarriage  of  her  first  child. 
Between  the  year  1757  and  August,  1783,  when  she 
died,  she  underwent  the  operation  of  tapping  eighty 
times;  and  in  these  operations  there  were  altogether 
removed  from  her  6,631  pints  of  fluid,  or  upwards  of 
thirteen  hogsheads.  One  hundred  and  eight  pints  was 
the  largest  quantity  ever  taken  away  at  one  time  ;  she  was 
never  tapped  more  than  five  times  in  one  year,  and  the 
largest  quantity  in  a  year  was  four  hundred  and  ninety- 
five  pints.  The  most  fluid  collected  in  the  shortest 
space  of  time  was  ninety  pints  in  seven  weeks,  from 
July  24lh  to  September  loth^  J  780,  which  is  very  nearly 
two   pints  a  day.      "On  the    loth   of  August,  1783,  the 


152  Diseases  of  the  Ovaries. 

poor  woman  died.  On  the  following  day,  on  opening 
the  body,  seventy-eight  pints  of  clear  fluid  were  drawn 
off.  Supposing,  therefore,  all  the  fluid  to  have  been 
taken  off  at  the  last  operation,  then  in  three  weeks  she 
had  collected  seventy-eight  pints,  which  is  more  than 
three  pints  and  a  half  each  day — a  quantity  far  exceeding 
what  she  had  taken."  The  disease  was  situated  in  the 
left  ovarium.  The  sac  is  in  the  collection  of  John 
Hunter,  Esq. 

The  history  of  the  case  is  recorded  by  Mr.  P.  M. 
Martineau,  surgeon  to  the  Norfolk  and  Norwich  Hospital, 
in  the  Philosophical  Transactions  for  1784,  vol.  Ixxiv. 
p.  471. 

Tombstones  have  been  used  to  record  less  remark- 
able cases.  In  Bunhill  Fields  burial-ground,  according 
to  T.  Saiford  Lee,"^'  there  is  an  old  tomb  (1728)  with  an 
inscription  to  the  effect  that  it  contains  the  body  of  Dame 
Mary  Page  ;  she  died  in  her  fifty-sixth  year.  "In  sixty- 
seven  months  she  was  tapped  sixty-six  times,  had  taken 
away  240  gallons  of  water."  Lee  writes:  "She  was  a 
patient  of  Dr.  Mead,  who  mentions  the  case."  Lawson 
Taitf  mentions  a  similar  epitaph  in  a  churchyard  at 
Romsey,  Hampshire,  declaring  that  Mary  Dawkins,  aged 
ninety  years,  had  been  tapped  for  dropsy  forty-six  times. 
The  date  on  the  stone  is  1826.  Peaslee  %  has  collected 
some  extraordinary  cases  of  this  kind  from  American 
literature. 

The  rupture  of  an  ovarian  cyst  is  sometimes  attended 
with  haemorrhage,  or,  what  is  more  probable,  the  escape 
of  fluid  may  relieve  the  tension,  and  free  bleeding  takes 
place  into  the  cavity  of  the  cyst.  Rapidly  fatal  haemorr- 
hage from  rupture  of  an  ovarian  cyst  is  usually  associated 

*  O/i  Tumours  of  the  Uterus,  etc.  (Jacksonian  Essay),  p.  166  ;  1847. 
t  Edin.  Med.  Journal,  July,  1889,  p.  7. 
J  Ovarian  Tumours,  p.  40, 


COLLOIDKNITTERM.  153 

with  axial  rotation  of  the  tumour  :  an  accident  which  has 
been  fully  considered.  When  a  multilocular  cyst  bursts, 
the  fluid  which  escapes  is  rarely  great,  for  as  it  flows 
through  the  rent  it  carries  before  it  a  secondary  cyst, 
which  quickly  plugs  the  opening. 

When  the  fluid  is  mucoid  or  colloid  in  character,  it  is 
not  tolerated  so  easily  by  the  peritoneum,  and  peritonitis 
may  result.  The  omentum  becomes  thickened  and 
dotted  with  small  opaque  bodies,  and  the  peritoneum  is 
injected  and  roughened,  sometimes  giving  rise  to  a  kind 
of  faint  crepitus  when  palpated. 

Olshausen*  refers  to  this  peculiar  crepitation  as 
colloidkjiittern,  but  says  it  may  be  perceived  in  relation 
with  unruptured  cysts. 

When  cysts  containing  papillomatous  masses,  or 
malignant  growth,  rupture,  portions  of  the  debris  are 
scattered  far  and  wide  through  the  peritoneal  cavity,  and 
become  engrafted  on  the  peritoneum.  The  effects  of 
this  in  relation  to  papillomatous  cysts  has  already  been 
considered  in  chapter  ix. 

When  describing  the  distribution  of  the  pelvic  peri- 
toneum, mention  was  made  of  a  case  in  which  a  secondary 
process  of  this  membrane  descended  towards  the  peri- 
neum, behind  the  vagina. 

Matthews  Duncan,!  in  some  interesting  Notes  on  the 
Morbid  Anatomy  of  Douglas's  Pouch,  refers  to  the  case 
of  a  woman,  a  patient  in  the  Royal  Infirmary,  Edinburgh, 
who  had  a  large  ovarian  cyst,  which  burst  and  discharged 
so  copious  an  amount  of  very  viscid  clear  jelly  as  to  dis- 
tend her  abdomen  extremely ;  it  was  too  viscid  to  flow 
through  a  trocar.  In  the  latter  weeks  of  the  woman's 
life  a  rounded  firm  tumour  protruded  from  the  vagina. 


*  Krankheiten  der  Ovarien,  s.  119. 

t  St.  BartholometJs  Hospital  Reports,  vol.  xvii.  p.  i. 


154  Diseases  of  the  Ovaries. 

At  the  post  mortem  examination  it  was  found  to  be 
a  hernial  protrusion  of  the  peritoneum  of  Douglas's 
pouch.  At  the  bottom  of  the  fossa  was  an  opening 
admitting  two  fingers,  which  established  communication 
with  the  hernial  sac,  descending  between  the  rectum  and 
vagina,  and  then  protruding  the  latter.  The  sac  was 
larger  than  a  hen's  ^gg.  It  was  full  of  very  viscid 
gelatinous  ovarian  fluid,  which  adhered  to  its  peritoneal 
surface. 

Rupture  of  ovarta?t  cysts  into  holloiv  viscet^a. — It  has 
already  been  shown  that  ovarian  cysts,  especially  der- 
moids, are  prone  to  inflame  and  contract  adhesions  to  the 
adjacent  portions  of  the  alimentary  canal,  especially  the 
rectum.  Such  adhesions  produce  intimate  union  of  the 
parts,  and  subsequent  osmosis  of  intestinal  gases  leads  to 
suppuration  of  the  cyst,  the  pus  finding  an  escape 
through  the  rectum  by  means  of  a  fistula  which  forms 
between  it  and  the  cyst. 

Communication  may  take  place  between  the  cyst  and 
an  adjacent  loop  of  gut  in  the  same  method  by  which 
adjacent  cysts  communicate ;  the  continuous  pressure 
that  they  exert  upon  each  other  produces  absorption  of 
the  tissues  forming  their  walls. 

The  results  of  such  changes  are  interesting.  The 
museum  of  St.  Bartholomew's  Hospital  contains  a  speci- 
men thus  described  in  the  catalogue  : — 

"  Portion  of  a  cyst  originating  in  the  left  ovary.  It  communi- 
cated with  the  ileum  by  a  small  aperture  between  four  and  five 
inches  above  the  ileo-ccecal  valve.  Some  weeks  before  death,  after 
the  discharge  of  a  large  cjuantity  of  fluid  fer  aiiii/ii,  the  abdominal 
tumour  diminished  in  size,  and  the  dulness  to  percussion  over  its 
region  was  replaced  by  tympanitic  resonance." 

Dr.  Murchison*  has  recorded  an  instance  in  which  an 

*  Diseases  of  the  Liver,  p.  465  ;   ist  ed. 


Rupture  from   Violexce.  155 

ovarian  cyst  opened  into  the  rectum,  the  complication 
being  recognised  during  Hfe : — The  patient  was  thirty-seven 
years  old  ;  on  her  admission  into  Middlesex  Hospital 
the  abdomen  was  found  considerably  distended  by  a 
tumour  rising  above  the  pubes,  and  reaching  higher  than 
the  umbilicus.  The  tumour  was  dull  on  percussion,  and 
distinctly  fluctuated.  A  few  days  after  admission  the 
patient  suffered  from  diarrhoea,  dry  tongue,  rapid  and 
feeble  pulse  \  there  was  considerable  tenderness  over  the 
tumour.  Fourteen  days  later  a  quantity  of  pus  passed 
with  the  motions,  and  continued  to  pass  for  three  days. 
Six  days  later  the  tumour  could  not  be  felt  above  the 
pubes,  and  she  died  shortly  after.  At  the  post  mortem 
examination  a  collapsed  cyst  the  size  of  a  cocoa-nut  re- 
placed the  left  ovary;  it  had  emptied  itself  by  an  opening 
the  size  of  a  fourpenny-piece  into  the  rectum  four  inches 
above  the  anus.  There  was  no  ulceration  of  the  mucous 
membrane  of  rectum  round  the  opening  in  the  cyst. 
The  sigmoid  flexure  of  the  colon  and  the  tip  of  the 
vermiform  appendix  were  firmly  adherent  to  the  walls  of 
the  cyst. 

Bright  *  relates  the  details  of  a  case  which  occurred 
at  Guy's  Hospital.  A  young  woman,  twenty- two  years 
of  age,  had  felt  a  tumour  in  the  right  iliac  fossa  for 
about  a  year.  Three  months  before  admission  diarrhcea 
came  on,  and  the  tumour  diminished.  Four  months 
after  admission  she  died.  At  the  post  mortem  examina- 
tion a  cyst  about  six  inches  long,  and  probably  ovarian, 
was  found  adherent  to  and  communicating  with  the 
caecum. 

Rupture  from  :oiolence. — Beaumont  f  mentions  an 
example  of  this.      A  woman  who  had  laboured  under 


*  Clin.  Memoirs,  p.  104  ;  Syden.  Soc. 

t  Bright's  Clinical  Memoirs,  p.  121  ;    Syden.  Soc. 


156  Diseases  of  the  Ovaries. 

ovarian  dropsy  many  years  fell  from  some  high  steps  in 
brushing  the  ceiling  of  a  very  lofty  room,  and  burst  the 
sac.  Two  days  after  the  accident  she  was  seen  by  Mr. 
Beaumont,  who  found  her  without  pain,  but  feeble ;  her 
attendant  produced  three  large  chamber-pots  full  of 
urine  which  she  had  passed  in  twenty-four  hours,  and 
which  increased  quantity  continued  for  four  or  five  days 
afterwards.  She  never  filled  again;  but  became  very 
thin  and  emaciated,  and  died  in  London  two  years  after- 
wards. 

Barnes'^  briefly  records  the  case  of  a  woman  with  an 
ovarian  tumour  who  was  descending  in  the  lift  at  the  old 
St.  Thomas's  Hospital.  The  machinery  gave  way,  and 
the  lift  came  down  with  a  run.  The  concussion  burst 
the  cyst.  Copious  diuresis  followed.  The  woman  re- 
covered. 

Wiltshire!  has  recorded  an  instance  in  which  a  lady 
with  an  ovarian  cyst  stood  up  in  a  hansom  cab  to  speak 
to  the  driver  through  the  trap  in  the  roof.  The  horse 
fell,  and  she  was  thrown  forward  on  the  sharp  angle  of 
the  corner  of  the  door,  and  burst  the  cyst.  The  patient 
recovered.  When  an  ovarian  cyst  complicates  preg- 
nancy, the  cyst,  if  allowed  to  remain,  not  infrequently 
impedes  delivery,  and  is  ruptured. 

Ovarian  cysts  have  been  accidentally  ruptured  in  a 
variety  of  ways  :  e.g.  during  an  immoderate  fit  of  laughter, 
in  stooping  to  butto7i  the  boots.,  or  even  during  the  mani- 
pulation of  the  physician.  Among  other  causes  may  be 
mentioned  vomiting  and  cougliing,  but  by  far  the  most 
frequent  cause  is  a  fall. 

W^hen  the  tumour  is  very  large,  and  extends  upwards 
beyond  the    umbilicus,    it   leads    to    displacement   and 


*  Diseases  of  Womc/i,  p.  339  ;   1873. 

f   Trans.  Clin.  Soc,  London,  vol.  xv.  p,  i. 


Pressor e  Effects — H\ 'DRnNEPiiROsis.       1 5  7 

distortion  of  the  abdominal  organs,  and  the  diaphragm  is 
pushed  upwards,  and  encroaches  upon  the  cavity  of  the 
thorax.  When  the  cyst  is  very  large,  the  lower  ribs  may 
be  turned  outwards,  the  intercostal  spaces  widened,  and 
the  lower  portions  of  the  lungs  become  atelectic  from 
pressure.  Such  conditions  seriously  impair  respiration, 
and  lead  to  pleural  effusion,  dyspnoea,  and  death.  Fortu- 
nately, at  the  present  day  such  conditions  are  rarely  wit- 
nessed, as  the  patients,  inspired  by  the  great  success 
that  now  attends  abdominal  surgery,  usually  seek  relief 
before  the  tumours  attain  such  large  dimensions. 

The  tumour  may  press  upon  the  veins  at  the  brim  of 
the  pelvis,  and  give  rise  to  oedema  of  the  lower  limbs,  or 
if  the  inferior  vena  cava  is  pressed  upon,  fluid  will  accu- 
mulate in  the  belly. 

Occasionally,  when  the  tumours  are  impacted  in  the 
pelvis,  they  will  press  upon  the  rectum,  and  cause 
obstruction  to  the  passage  of  fseces,  or  press  upon  the 
bladder,  and  give  rise  to  frequent  or  painful  micturition. 

By  far  the  most  important  complications  arising  from 
pressure  exerted  by  these  tumours  are  those  which  occur 
when  one  or  both  ureters  are  compressed.  The  renal 
changes  that  complicate  ovarian  tumours  form  two  dis- 
tinct groups : — 

1.  Changes  due  to  mechanical  interference  with  the 

escape  of  urine — hydronephrosis. 

2.  Inflammatory  changes  originating  in  the  bladder. 

When  the  free  flow  of  urine  down  the  ureter  is  inter- 
fered with,  in  consequence  of  the  compression  of  this 
duct  by  a  tumour,  the  retained  fluid  causes  at  first  disten- 
sion of  the  ureter  and  the  renal  pelvis.  If  the  obstruction 
continue,  it  will  lead  to  sacculation  of  the  kidney,  and 
finally  absorption  of  the  secreting  tissue  of  this  organ, 
.which  at  length  becomes  converted  into  a  retention 
cyst — a    condition  of  the   kidney   conveniently   termed 


158  Diseases  or  the  Oi'ak/es. 

Iiyclroiieplirosi**).  '^I'here  are  few  facts  at  our  disposal 
relative  to  the  frequency  with  which  hydronephrotic  dis- 
tension of  the  kidney  complicates  ovarian  cysts,  because 
the  condition  when  caused  by  these  tumours  is,  as  a  rule, 
unilateral,  and  unless  very  large,  rarely  attracts  attention. 

Henry  Morris,  in  his  well-known  admirable  mono- 
graph on  Surgical  Diseases  of  the  Kidney,  points  out : 
"  When  the  dilatation  is  insuflficient  to  give  rise  to  a 
tumour,  there  are  generally  no  symptoms  characteristic 
of  hydronephrosis  :  it  is  simply  a  silent  complication,  or 
consequence,  of  some  other  condition  to  which,  and  not 
to  the  insidious  changes  going  on  in  the  kidney,  the 
attention  of  the  surgeon  or  physician  is  called." 

Hydronephrosis,  secondary  to  the  pressure  of  an 
ovarian  cyst  on  one  or  both  of  the  ureters,  has  been 
several  times  recorded,  in  which  the  dilated  kidney  was 
large  enough  to  become  conspicuous  clinically. 

Treves'''  published  an  account  of  a  case  in  which 
hydronephrosis  was  produced  by  the  pressure  of  ovarian 
cysts. 

Each  ovary  was  occupied  by  a  multilocular  cyst  the 
size  of  a  hen's  egg ;  the  left  kidney  was  hydronephrotic, 
the  right  one  was  healthy.  Both  ovaries  were  removed  by 
abdominal  section,  as  well  as  the  affected  kidney.  The 
patient's  convalescence  was  retarded  by  peritonitis,  but 
eventually  she  recovered. 

It  is  essential  in  all  cases  of  hydronephrosis,  especially 
when  both  kidneys  are  affected,  to  examine  the  pelvic 
organs. 

Thorntont  has  recorded  a  case  in  which  Sir  Spencer 
Wells  opened  a  hydronephrotic  cyst  in  the  loin  ;  subse- 
quently an  ovarian  cyst  was  removed,  and  finally  the 
remaining  kidney  was  incised  and  drained. 

*  Lancet,  Sept.  24th,  1887. 

t  Med.  Times  a7id  Gazette,  18B3,  vol.  i.  p.  624. 


Pressure  Effects — Nephritis.  159 

There  is  a  form  of  renal  disturbance  caused  by 
large  ovarian  and  parovarian  cysts  to  which  Sir 
Spencer  Wells  has  directed  attention,  and  which  is 
obviously  the  result  of  the  pressure  exercised  by  the 
tumour.  This  disturbance  is  indicated  by  the  voiding  of 
"only  a  small  quantity  of  highly  concentrated  urine^, 
depositing  mixed  urates  in  abundance."  So  much  im- 
portance does  this  surgeon  attach  to  it  that  he  writes  ; — 
"  If  ovariotomy  be  performed  on  a  patient  in  this 
condition,  a  serious  amount  of  kidney  congestion,  with 
symptoms  almost  amounting  to  ursemic  fever,  is  almost 
certain  to  follow  the  operation.'^  He  also  recommends 
the  employment  of  lithia  in  various  forms  in  order  to 
"  clear  the  urine." 

Doran  is  of  opinion  that  clinical  evidence  makes  it 
appear  that  the  excretion  of  small  quantities  of  urine 
loaded  with  pink  urates  is  entirely  due  to  the  pressure  of 
the  tumour  ;  and  that  if  the  cyst  be  tapped  the  urine  is 
at  once  secreted  in  greater  quantities,  and  less  charged 
with  solid  constituents. 

I  have  seen  these  conditions  associated  with  oedema 
of  the  legs,  and  w^ithout  the  least  trace  of  albumen  in  the 
urine,  and  have  regarded  it  as  an  indication  for  urging, 
rather  than  deferring,  the  removal  of  the  tumour. 

The  precise  cause  of  the  diminution  in  the  quantity 
of  urine  secreted  under  such  conditions  is  not  very  clear. 

Beck  has  shown  that  "  three  chief  causes  are  at  work, 
in  various  degrees,  in  the  production  of  secondary  renal 
disease  : — (i)  Increased  pressure  in  the  tubules  from 
obstruction  to  the  escape  of  urine  ;  (2)  reflex  irritation  of 
the  kidney  ;  (3)  the  presence  of  septic  matter  in  the 
pelvis  of  the  kidney." 

As  a  rule,  increased  backward  pressure  will  produce 
hydronephrosis,  whereas  reflex  irritation  will  excite  the 
transient  or  congestive  types  of  urinary  fever.     Morris,  in 


l6o  I?/SE.lSi:S    OF    THE    Ol' ARIES. 

regard  to  reflex  irritation,  believes  that  it  alone  occasion- 
ally excites  the  inflammatory  form  of  urinary  fever  :  i.e. 
acute  or  sub-acute  interstitial  nephritis.  It  seems, 
therefore,  reasonable  to  believe  that  the  scanty  secretion 
of  urine  possessing  a  high  specific  gravity  in  association 
with  ovarian  cysts  is  due  to  partial  obstruction  of  the 
ureter,  leading  to  increased  pressure  in  the  urinary 
tubules,  accompanied,  in  some  cases,  by  what  we  term, 
for  want  of  more  accurate  knowledge,  reflex  irritation  of 
the  kidney.  It  also  seems  clear  that  a  persistence  of  such 
conditions,  short  of  causing  complete  obstruction,  and  its 
necessary  consequence,  hydronephrosis^  will  lead  to  those 
profound  textural  alterations  in  the  kidney  which  may 
be  expressed  by  the  phrase  "  chronic  interstitial 
nephritis." 

We  must  now  consider  the  more  serious  condition, 
when  inflammatory  changes  in  the  bladder  and  kidney 
are  associated  with  the  presence  of  an  ovarian  cyst. 

Cystitis  may  occur  in  a  patient  with  an  ovarian 
tumour  as  a  consequence,  or  independently,  of  its  pre- 
sence. Under  any  condition  it  is  a  serious  complication. 
It  is  not  the  cystitis  that  the  surgeon  fears  so  much  as 
the  morbid  changes  it  induces  in  the  kidneys.  When 
fermentation  of  urine  occurs  in  the  bladder,  the  agents  by 
which  this  change  is  induced  pass  by  way  of  the  ureters 
to  the  renal  pelvis,  and  the  inflammation  thus  excited 
extends  thence  into  the  substance  of  the  kidneys,  giving 
rise  to  suppurative  nephritis  and  pyonephrosis,  conditions 
which  surgeons  too  well  know  always  increase  the  risks 
of  surgical  operations  of  all  kinds. 

The  dangers  of  such  conditions  to  patients  who  are 
submitted  to  ovariotomy  is  shown  by  Doran's  statement, 
"that  in  thirty-two  out  of  over  forty  necropsies  I  have 
made  on  the  bodies  of  patients  who  have  died,  either 
after  ovariotomy   or   with  large  ovarian  tumours  in  the 


Intestinal  Obstruction.  i6i 

abdomen,  I  have  found  that  the  kidneys  presented  very 
distinct  morbid  appearances.  The  clinical  evidence  was 
strong  that  in  the  majority  of  these  cases  the  disease 
was  due  to  the  presence  of  a  tumour." 

Ititestinal  obstruction  caused  by  ovarian  cysts. — 
Several  cases  have  been  recorded  in  which  intestinal 
obstruction  has  been  caused  by  ovarian  cysts.  This 
accident  may  be  due  to  a  piece  of  gut  becoming 
strangulated  round  the  pedicle  of  a  cyst. 

Hilton  Fagge  reported  an  example  of  this.*  A  woman, 
seventy-four  years  of  age,  was  admitted  into  Guy's  Hos- 
pital in  1863  with  symptoms  of  strangulated  hernia,  and 
died  six  days  later.  At  the  J>ost  mortem  examination  a 
piece  of  ileum  was  found  strangulated  by  passing  round 
the  pedicle  of  an  ovarian  cyst. 

Mundet  reported,  for  Dr.  Henry,  a  case  in  which  fatal 
intestinal  obstruction  resulted  from  the  ileum  being 
strangulated  by  the  pedicle  of  an  ovarian  cyst  holding 
about  a  pint  of  fluid.  The  pedicle  was  six  inches  in 
length,  and  the  obstruction  occurred  about  twelve  inches 
above  the  ileo-csecal  valve.  The  patient  was  forty-five 
years  of  age.  The  symptoms  were  those  of  acute  intes- 
tinal obstruction. 

M.  Ricardi  describes  a  most  instructive  case  where 
acute  symptoms  of  obstruction  came  on  in  a  waitress  at 
a  restaurant,  aged  twenty-four.  Intense  pain  in  the  right 
side  of  the  abdomen  set  in  when  she  was  at  work.  She 
had  to  go  home ;  furious  vomiting  occurred,  and  at  the 
end  of  the  second  day  it  became  faecal.  Three  days 
later  she  was  sent  to  hospital  in  a  state  of  collapse,  with 
all  the  symptoms  of  acute  peritonitis.  The  abdomen 
was  opened,  and  a  dermoid  ovarian  cyst  was  found  in  the 

*  Guy's  Hospital  Reports,  vol.  xiv.  p.  357. 
t  A7n.  Jozi?-?tal  of  Obstet.,  vol.  xiii.  p.  388. 
X  Cgz.  des  Hopitaux,  January  ist,  1891, 


1 62  Diseases  oe  the  Ovaries. 

right  iliac  fossa,  covered  with  adherent,  inflamed,  and 
distended  intestines.  These  were  detached,  and  then 
two  pedicle-Hke  structures  were  f6und.  The  inner  and 
upper  proved  to  be  formed  by  four  inches  of  small  intes- 
tine, perfectly  empty  and  intimately  adherent  to  the  cyst, 
whence  it  had  to  be  carefully  dissected.  The  lower  was 
a  true  pedicle,  twisted,  thick,  and  fleshy.  The  tumour 
was  removed.  On  the  third  day  the  bowels  acted 
spontaneously.  The  pain  and  vomiting  ceased  immedi- 
ately after  the  operation.  Recovery  was  perfect.  The 
close  adhesion  of  the  intestine  to  the  cyst  was  evidently 
the  cause  of  the  obstruction.  Before  the  attack  of  pain, 
which  seized  the  patient  quite  suddenly,  she  had  never 
been  ill,  never  felt  abdominal  pain,  and  never  noticed 
any  tumour  in  the  hypogastrium.  The  menstrual  periods 
had  been  normal.  Notwithstanding  these  negative  symp- 
toms, a  small  ovarian  tumour  existed,  and  caused  acute 
obstruction. 


i63 


CHAPTER    XV. 

THE    DIAGNOSIS    OF    OVARIAN    TUMOURS. 

The  diagnosis  of  ovarian  tumours  involves  the  question 
of  the  diagnosis  of  abdominal  swellings  in  general. 
Indeed,  there  is  no  organ  in  the  belly,  except  the  supra- 
renal capsule,  which  has  not  at  some  time  or  other  given 
rise  to  signs  resembling  those  presented  by  an  ovarian 
cyst.  These  facts  alone  will  serve  to  show  that  there  is 
no  pathognomonic  sign  indicative  of  an  ovarian  tumour. 
In  many  cases  the  methods  of  physical  examination  are 
incompetent  to  enable  us  to  form  a  correct  opinion  of 
the  nature  of  an  abdominal  tumour  until  it  has  been 
actually  exposed  to  view ;  even  with  the  abdomen  open 
doubts  and  difficulties  sometimes  arise.  The  subject 
will  be  discussed  in  this  work  in  the  following  sections  : — 

1.  Tumours  which  occupy  the  pelvis  and  abdomen. 

2.  Tumours  restricted  to  the  pelvis. 

3.  Tubal  pregnancy. 

Metliod  of  examination.— When  a  patient  sus- 
pected to  have  an  ovarian  tumour  comes  under  observa- 
tion, it  is  the  duty  of  the  surgeon  or  physician,  as  the  case 
may  be,  to  inquire  into  the  history  of  the  case :  information 
concerning  the  age,  social  condition,  and  menstrual  history 
is  often  as  important  in  diagnosis  as  a  knowledge  of  the 
general  physical  condition  of  the  patient  and  the  facts 
she  may  be  able  to  relate  concerning  the  tumour  itself. 

In  conducting  the  physical  examination  of  the  patient, 
she  should,  whenever  possible,  be  undressed,  for  nothing 
is  so  unsatisfactory  as  exploring  an  abdomen  to  ascertain 
L  2 


164  Diseases  oe  the  Ovaries. 

the  existence  or  nature  of  a  tumour  when  the  parts  are 
encumbered  by  partially  loosened  skirts,  petticoats,  stays, 
and  other  garments. 

The  patient  should  be  placed,  when  undressed,  with 
her  back  flat  upon  a  bed  or  couch,  and  the  legs  covered 
with  a  sheet  or  blanket,  and  the  surgeon  should  be  careful 
that  his  hands  and  finger-tips  are  not  cold,  as  this  is  most 
uncomfortable  to  the  patient,  and  hinders  a  proper  ex- 
amination. 

In  a  typical  case  of  ovarian  tumour  the  size  of  the 
abdomen  is  increased.  With  a  big  cyst  the  enlargement 
is  general,  but  locahsed  when  the  tumour  is  of  moderate 
dimensions  to  one  or  other  flank.  Local  enlargements 
are  always  most  marked  below  the  level  of  the  umbilicus. 
The  skin  of  the  abdomen  sometimes  presents  a  brown 
discoloration,  and  the  superficial  veins  may  be  dis- 
tended. 

On  palpation,  the  swelling  feels  firm  and  resisting.  In 
cystic  tumours  its  surface  is  uniform,  as  a  rule,  but  multi- 
locular  cysts  may  have  an  irregular  surface ;  this  is  also 
true  of  ovarian  adenomata.  Manipulation  rarely  causes 
pain.  In  large  cysts  a  wave  of  fluctuation  can  easily  be 
produced ;  in  multilocular  cysts  this  sign  is  restricted  to 
the  large  cavities.  The  distinctness  with  which  the  wave 
is  perceived  depends  upon  the  character  of  the  fluid  and 
the  thickness  of  the  abdominal  wall. 

Percussion  furnishes  valuable  evidence.  The  crown 
and  sides  of  the  swelling  are  quite  dull,  but  on  approaching 
the  loins  the  dulness  gradually  gives  way  to  resonance. 
If  now  the  patient  is  turned  to  one  or  other  side,  we  shall 
find  that  the  alteration  in  position  does  not  affect  the 
percussion  note.  Auscultation^  as  a  rule,  gives  no 
information.  Gurgling  of  intestines  and,  occasionally,  the 
pulsation  of  the  aorta  may  be  perceived,  and  very  rarely 
a  briiit  has  been  detected.     In  non-ovarian  tumours  this 


Diagnosis  of  Ovarian  Tumours.  165 

method  of  physical  examination  often  affords  valuable 
information.  After  examining  the  abdomen,  the  surgeon 
should  explore  the  parts  by  an  internal  examination.  As 
a  rule,  this  is  best  made  through  the  vagina,  but  in  young 
unmarried  girls  it  will  sometimes  be  necessary  to  make 
the  examination  by  the  rectum.  The  surgeon  can  then 
ascertain  the  relation  of  the  tumour  to  the  uterus,  the 
condition  of  this  organ,  and  the  state  of  the  rectum.  In 
uncomplicated  cases  of  ovarian  tumour  the  information 
furnished  by  a  vaginal  or  rectal  examination  is  negative, 
but  it  should  always  be  undertaken,  as  it  is  not  infre- 
quently of  the  greatest  value  in  enabling  the  surgeon  to 
detect  complications  previously  unsuspected. 

Lastly,  the  urine  should  be  examined  ;  this,  for  some 
curious  reason,  is  strangely  neglected  by  surgeons,  yet  it 
often  furnishes  very  significant  warning. 

The  recognition  of  a  large  uncomplicated  ovarian  or 
parovarian  cyst  is  one  of  the  simplest  processes  in  clinical 
surgery.  The  signs  may  be  thus  summarised  : — A  swelling 
of  the  abdomen  most  marked  below  the  umbilicus, 
associated  with  absolute  dulness  to  percussion  all  over 
the  tumour,  most  marked  on  its  summit,  and  tailing  away 
to  resonance  in  the  flanks  ;  such  dulness  is  not  affected  by 
alteration  in  the  position  of  the  patient.  If  such  signs  be 
associated  with  a  uterus  of  normal  size,  the  presumption 
that  the  swelling  is  an  ovarian  tumour  is  more  certain 
than  most  things  in  clinical  medicine. 

The  diagnosis  of  simple  cases  of  ovarian  tumour 
rarely  gives  rise  to  difficulty  if  the  surgeon  duly  weighs 
the  various  signs  together,  and  does  not  place  too  much 
reliance  on  any  one  of  them.  Difficulty  arises  sometimes 
in  distinguishing  between  ovarian  tumours  and  conditions 
which  simulate  them  ;  the  greatest  care  and  skill  are 
needed  when  diagnosis  is  complicated  by  secondary 
changes  in  the  cyst,   and  by  the  co-existence  of  other 


i66  .  Diseases  of  the  Ovaries. 

tumours,  abnormal  conditions  of  the  abdominal  viscera, 
ascites,  or  pregnancy. 

Some  of  the  more  important  conditions  which  simu- 
late ovarian  tumours  will  now  be  considered. 

Ascites.— Fluid  accumulations  in  the  peritoneal  cavity- 
are,  as  a  rale,  readily  distinguished  from  ovarian  cysts, 
but  many  instances  are  known  in  which  ascites  has  been 
mistaken  for  an  ovarian  cyst,  and  vice  versa. 

Under  the  general  term  ascites  it  is  usual  to  include 
all  serous  effusions  into  the  peritoneum  occurring  from 
obstruction  to  the  portal  circulation,  renal  or  cardiac 
disease.  The  form  of  dropsy  which  gives  rise  to  most 
difficulty  in  the  physical  examination  of  the  abdomen  is 
that  which  complicates  chronic  peritonitis,  due  to 
tubercle,  cancer  of  the  abdominal  viscera  and  peritoneum, 
and  salpingitis.  Ascites  accompanies  certain  forms  of 
ovarian  tumour. 

In  well-marked  ascites  there  is  rarely  any  difficulty 
in  diagnosis  ;  the  abdomen  is-  uniformly  enlarged ;  when 
the  patient  lies  on  her  back  the  fluid  occupies  the  flanks, 
and  when  abundant  the  sides,  of  the  belly  form  a  convex 
curve  from  the  lower  ribs  to  the  crest  of  each  iHum.  On 
percussion,  the  flanks  and  lower  half  of  the  abdomen  are 
dull,  whilst  around  the  umbilicus  a  clear  resonant  note  is 
obtained.  If  the  patient  be  now  turned  to  one  or  other 
side,  the  conditions  are  reversed;  the  higher  flank  becomes 
resonant  and  the  umbilical  region  dull.  This  shifting 
dulness  is  the  most  characteristic  sign  of  ascites.  In 
addition,  when  the  fluid  is  present  in  sufficient  quantity 
a  percussion  wave  may  be  easily  produced  from  side 
to  side. 

The  condition  most  likely  to  be  mistaken  for  ascites 
is  a  large  unilocular  cyst.  The  form  of  ascites  which 
most  simulates  an  ovarian  cyst  is  a  rare  variety^  termed 
encysted  dropsy. 


Ascites.  167 

Large  passive  effusions  of  fluid  in  the  peritoneal  cavity, 
secondary  to  hepatic,  renal,  or  cardiac  disease,  are  very 
rarely  a  source  of  difficulty  ;  the  history  of  the  case,  the 
general  aspect  of  the  patient,  and  the  physical  signs  con- 
nected with  the  circulation,  such  as  oedema  of  the  limbs, 
cardiac  murmurs,  distended  superficial  veins,  and  the 
like,  all  serve  to  put  us  on  our  guard.  It  is  the  acute 
effusions  that  complicate  malignant  conditions  of  the 
abdomen  which  give  trouble  in  diagnosis,  and  need  con- 
sideration, for  they  sometimes  deceive  and  mislead  the 
most  experienced  men. 

In  cases  of  tubercular  peritonitis  the  intestines  are  so 
matted  together  and  thickened  that  they  may  occasionally 
furnish  a  dull  percussion  note  in  the  middle  of  the 
abdomen^  especially  when  the  omentum  forms  a  broad 
thick  band  on  the  surface  of  the  fluid  near  the  um- 
bilicus, and  the  intestines  are  matted  together. 

Matthews  Duncan*  writes  : — "  In  several  cases  an 
ovarian  tumour  has  been  diagnosed,  the  belly  opened, 
and  nothing  found  but  coherent  ■  omentum  and  intes- 
tines." 

A  very  rare  form  of  ascites  which  simulates  an  ovarian 
cyst  is  when  the  fluid  is  restricted  to  the  lesser  cavity 
of  the  peritoneum,  due  to  occlusion  of  the  foramen  of 
Winslow.  Lawson  Tait  records  an  instance  wherein  he 
diagnosed  a  parovarian  cyst  in  a  young  girl,  and  opened 
the  abdomen  to  remove  it,  but  found  "that  it  was  not  a 
c)'st  of  the  broad  ligament,  but  dropsical  distension  of  the 
lesser  bag  of  the  perito?ieuni,  due  to  occlusion  of  the  com- 
municating cavity  by  peritonitis.  The  inflammation  was 
general,  and  in  spite  of  drainage  she  died  of  the  disease 
in  a  few  days.  At  the  post  mortem  examination  it  was 
found  that  the  whole  mischief  was  due  to  a  common 

*  Perimetritis  and  Parametritis,  p.  87. 


i68  Diseases  of  the  Oi^arieS. 

seamstress's  sewing-needle  lying  in  the  great  omentum, 
just  over  the  foramen  of  Winslow."  * 

The  parts  which  formed  the  boundaries  of  the  fluid, 
containing  space  in  this  remarkable  case  are  preserved  in 
the  museum  of  the  Royal  College  of  Surgeons,  London. 
The  catalogue  states  that  "  the  patient  was  a  lunatic." 

A  similar  form  of  dropsy  of  the  lesser  bag  of  peri- 
toneum has  been  found  associated  with  an  old  hepatic 
abscess.  Some  of  the  cases  vaguely  described  as  encysted 
dropsy  of  the  peritoneum  were  probably  hydatid  cysts. 

Ascites  due  to  secondary  cancer  of  the  peritoneum, 
malignant  tumours  of  the  ovary,  and  papillomatous 
(paroophoritic)  cysts,  is  often  associated  with  grave  consti- 
tutional disturbance,  such  as  emaciation,  general  anasarca, 
sometimes  pain  and  the  appearance  which  is  termed 
cachexia,  that  usually  indicates  to  the  shrewd  practitioner 
the  character  of  the  disease. 

Many  attempts  have  been  made  to  detect  among  the 
fiiiids  found  in  ovarian  cysts  characters,  chemical,  micro- 
scopic, or  spectroscopic,  which  would  serve  to  distinguish 
them  from  passive  or  inflammatory  effusions  into  the 
peritoneum.  Not  only  have  the  attempts  failed  in  this 
respect,  but  they  have  not  even  succeeded  in  detecting 
any  signs  by  which  it  could  be  definitely  decided  that  a 
given  sample  of  fluid  indicated  malignant  disease  of  the 
ovary  or  peritoneum. 

In  cases  where  it  is  impossible  to  come  to  a  positive 
diagnosis  between  the  two  conditions,  and  the  patient  is 
so  greatly  distressed  by  the  accumulation  that  it  is  neces- 
sary to  relieve  her  by  removing  the  fluid  or  cyst,  as  the 
case  may  be,  instead  of  adopting  the  unsatisfactory 
method  of  puncturing  the  abdomen  with  a  trocar,  I  make 
a  small  incision  in  the  linea  alba  capable  of  admitting  an 

*  Diseases  of  the  Ovaries,  p.  219  ;  1883. 


Ascites  and  Ovarian  Tumours.  169 

index  finger.  In  this  way  information  is  obtainable  in  a 
manner  impossible  by  other  means.  If  a  removable 
tumour  be  present,  the  incision  is  at  once  enlarged  and 
the  operation  completed.  Should  the  fluid  be  free  in 
the  peritoneum,  it  can  be  evacuated  through  the  incision 
quickly  and  more  completely  than  through  a  cannula,  and 
without  any  fear  of  wounding  a  piece  of  bowel  that  may 
chance  to  be  floating  on  the  fluid ;  and  if  necessary,  the 
cavity  may  be  washed  or  sponged  out. 

Ascites  is  an  almost  constant  accompaniment  of 
ovarian  sarcomata ;  it  must  not,  however,  be  inferred 
that  when  ascites  co-exists  with  an  ovarian  tumour  that 
it  necessarily  indicates  vialignancy .  It  is,  of  course,  a 
very  suspicious  sign,  but  many  instances  have  been 
observed  in  which  such  fears  have,  fortunately,  not  been 
realised. 

Ovarian  sarcomata  are  accompanied  by  other  signs 
as  well  as  ascites,  which  will  often  lead  to  a  correct 
diagnosis.  For  instance,  menstruation  is,  as  a  rule, 
irregular  :  in  some  it  is  suppressed,  in  others  increased  in 
quantity ;  it  may  even  be  diminished  at  one  period  and 
increased  at  another.  In  simple  ovarian  tumours  the 
menstruation  is  usually  unaffected.  Emaciation  is  the 
rule.  Age  lends  no  assistance,  as  malignant  ovarian 
tumours  have  been  reported  as  early  as  the  eighth  year. 
The  physical  signs  of  solid  ovarian  tumours  resemble 
rather  those  presented  by  uterine  myomata  than  ovarian 
cysts  ;  in  a  fair  proportion  of  cases  both  ovaries  are 
affected.  It  should  be  borne  in  mind  that  secondary 
cancer  attacks  the  ovaries,  especially  when  the  primary 
tumour  is  in  the  breast.  I  have  seen  well-advanced 
mammary  cancer  co-exist  with  an  ovarian  cyst.  It 
caused  some  difficulty  in  diagnosis,  as  it  gave  rise  to  the 
suspicion  that  the  abdominal  swelling  might  be  ascites, 
due  to  secondary  deposits  in  the  peritoneum. 


170  Diseases  of  the  Ovaries. 

The  prop07'tion  of  solid  to  cystic  ovarian  tumours  is 
about  five  of  the  former  to  one  hundred  of  the  latter. 

PhaBitoiii  tmiio 111'.— This  very  extraordinary  condi- 
tion, sometimes  called  spurious  pregnancy — a  term  which, 
according  to  Dr.  Robert  Barnes,  "has  been  Hellenised 
by  Mason  Good  into  Pseudocyesis  " — not  only  simulates 
pregnancy,  but  ovarian  and  other  abdominal  tumours, 
and  occurs  occasionally  in  men. 

The  symptoms  of  phantom  tumour  are  briefly  these ; 
a  woman  will  fancy  she  is  pregnant  or  suffering  from  a 
tumour,  and  states  that  her  abdomen  has  been  gradually 
increasing  in  size. 

These  cases  rarely  give  rise  to  difficulty.  When  the 
abdomen  is  submitted  to  physical  examination,  it  will  be 
found  everywhere  resonant,  and  loud  intestinal  gurgling 
is  usually  present ;  by  cautiously  engaging  the  patient  in 
conversation  during  the  manipulation,  the  belly  may  be 
pressed  quite  flat.  In  such  a  case  the  age  gives  im- 
portant indications,  especially  when  the  woman  is  long 
past  the  climacteric.  Again,  in  younger  women,  the 
other  signs  of  pregnancy,  such  as  enlargement  of  the 
breasts,  morning  sickness,  increase  in  the  size  of  the 
uterus,  and  amenorrhea,  are  wanting. 

If  after  a  physical  examination  the  surgeon  still  feels 
in  doubt,  an  anaesthetic  will  decide  the  question :  as  the 
patient  becomes  unconscious  the  abdomen  diminishes  in 
size  until  it  becomes  quite  flat ;  as  the  patient  returns  to 
consciousness  the  abdominal  distension  reappears. 

Bright  has  recorded  a  case  of  hysfe?-ical  distensio?i  of 
the  bowels^  mistaken  for  ovarian  tumour^  in  which  an 
operation  was  undertaken  to  attempt  its  ?-emoval. 

Susannah  J -,  aged  thirt)^,  came  under  his  care  in 

1824,  She  had  in  the  middle  line  of  the  abdomen,  about 
half  way  between  the  umbilicus  and  the  symphysis  pubis, 
an  unhealed  scar  of  about  three  inches'  in  length.     The 


Phantom  Tumour.  171 

account  the  woman  gave  was  that,  her  abdomen  being 
swollen,  a  surgeon  proposed  to  her  the  excision  of  a 
tumour  which  produced  this  swelling.  With  two  assistants 
he  prepared  to  perform  the  operation,  and  made  a  free 
incision  into  the  abdominal  cavity,  but  finding  there  was 
no  tumour,  brought  the  wound  together.  This  patient 
remained  in  the  hospital  three  months,  and  note  was  taken 
of  the  "occasional  puffing-up  of  the  abdomen."  The 
tumour  of  the  abdomen  varied  a  good  deal,  and  was  on 
one  or  two  occasions  reported  to  have  subsided  entirely. 

This  woman  had,  many  years  before,  been  under  Dr. 
Marcet's  care  for  a  supposed  abdominal  tumour,  who, 
however,  soon  discovered  its  hysteric  character :  though, 
certainly,  the  abdomen  bore  a  very  peculiar  appearance, 
strongly  resembling  an  encysted  tumour ;  but  there  were 
connected  with  this  supposed  tumour  so  many  other 
ailments,  embracing  fits  of  hysterics,  epilepsy,  paralysis, 
abdominal  and  lumbar  pains,  so  varied  and  so  changing, 
that  a  little  observation  was  sufficient  to  convince  any 
experienced  person  of  its  real  character.* 

Lizar's  celebrated  case  (page  200)  should  be  read  in 
conjunction  with  this. 

In  reference  to  Bright's  case,  T.  Safford  Leef  states 
that  the  patient  "gave  her  account  very  loosely,  and 
cannot  be  believed."  Lee  gives  a  table  of  six  cases,  with 
the  names  of  the  operators,  in  which  the  abdomen  was 
opened,  but  no  tumour  found. 

Phantom  tumour  occurs  more  especially  in  sterile 
women  who  have  married  late  in  life.  It  is  occa- 
sionally met  VN'ith  in  women  who  have  borne  children, 
and  now  and  then  in  young  wives.  Sometimes  it  is  seen 
in  women  who  have  subjected  themselves  to  illicit 
intercourse,  and  fear  the  results. 

*  Bright's  Clin.  Memoirs,  p.  137  ;  Syd.  Soc. 

f   Tumours  of  the  Uterus,  etc.  (Jacksonian  Essay),  p.  274;   1847. 


172  Diseases  of  the  Ovaries. 

Thus,  phantom  tumours  occur  under  two  opposite 
conditions  :  the  older  patients  have  often  a  morbid  desire 
for  pregnancy,  whilst  in  most  of  the  younger  ones  there 
is  a  dread  that  they  may  be  in  this  condition,  having  run 
the  risk  of  impregnation. 

As  to  the  cause  of  the  singular  mimicry  no  good 
explanation  is  forthcoming,  and  conditions  resembling  it 
have  been  reported  in  the  ass,  and  are  not  uncommon  in 
petted  bitches. 

It  is  difiicult  to  understand  how  this  condition  could 
be  mistaken  for  an  abdominal  tumour,  yet  more  than 
one  case  has  been  recorded  in  which  the  abdomen  was 
opened  to  remove  the  supposed  tumour.  Most  of  the 
cases  occurred  in  the  early  days  of  ovariotomy,  and  now 
that  surgeons  are  fully  aware  of  the  condition,  and  with 
the  assistance  afforded  by  an  anaesthetic,  such  blunders 
are  not  likely  to  be  made. 

A  patient  in  middle  or  advanced  life  sometimes 
imagines  she  has  dropsy  or  a  tumour  because  the  ab- 
domen has  increased  in  size;  on  examination  the  en- 
largement will  be  found  to  be  due  to  an  accumulation  ot 
subcutaneous  fat  and  tympanites. 

Tiiiiioiirs  of  tlie  uterus  and  preguaucy  not  in- 
frequently simulate  ovarian  tumours.  Of  all  forms  of  en- 
larged uterus,  pi'egnancy  is  the  one  most  likely  to  lead  to 
error,  and  especially  when  the  patient  may  have  some 
motive  for  concealing  her  true  condition.  In  some  in- 
stances patients  will  refuse  to  believe  that  they  are  pregnant 
until  the  pains  of  labour  convince  them  of  the  fact,  and 
even  then  they  cannot  always  be  convinced.  Sir  Spencer 
Wells  relates  the  following  case,  which  occurred  at  the 
Samaritan  Hospital.  The  patient  was  "  supposed  by  an 
experienced  surgeon  to  be  suffering  from  ovarian  tumour, 
but  she  denied  most  positively  the  possibility  of  preg- 
nancy ;  and  after  a  premature  labour,  probably  brought 


Pregnancy.  173 

on  by  detection  of  the  imposture,  accused  my  assistant, 
the  late  Dr.  Ritchie,  who  was  hastily  called  to  her,  ot 
having  brought  a  child  which  was  not  hers,  in  order  to 
shield  me  from  the  charge  of  having  made  a  mistake." 

In  cases  of  unmarried  women  the  greatest  caution  is 
necessary  before  expressing  an  opinion  that  the  case  is 
one  of  pregnancy ;  by  a  little  waiting  the  case  settles 
itself,  and  in  doubtful  conditions  nothing  is  to  be  gained 
by  giving  an  opinion  straight  away,  w^hereas  two  months 
is,  as  a  rule,  sufficient  to  lead  the  patient  to  thoroughly 
realise  her  condition,  and  she  may  not,  in  the  cir- 
cumstances, deem  it  necessary  to  trouble  the  surgeon  a 
second  time. 

The  co-existence  of  an  abdominal  swelling,  associated 
in  a  young  healthy  woman  with  fulness  of  the  breasts  and 
amenorrhoea,  is  a  combination  of  signs  always  sufficient 
to  put  us  on  our  guard,  and  if  on  auscultation  the  foetal 
heart  sound  and  the  uterine  bruit  can  be  heard,  or 
the  peculiar  rhythmical  contraction  is  perceived  when 
the  hand  is  placed  flat  upon  the  pregnant  uterus  and 
maintained  in  that  position,  the  diagnosis  is  not  very 
doubtful.  These,  apart  from  other  minor  signs  which 
can  be  taken  into  consideration,  are  not  likely  to  mislead 
a  careful  practitioner. 

To  mistake  a  gravid  uterus  for  an  ovarian  tumour  is 
an  awkward  blunder,  but  it  is  even  more  unpleasant  to  err 
in  the  converse  direction,  and  declare  a  young  unmarried 
woman  with  an  ovarian  tumour  to  be  pregnant.  Judging 
from  my  own  observations  on  the  cases  sent  ujd  as  ab- 
dominal tumours,  which  on  careful  and  systematic  ex- 
amination turn  out  to  be  unmistakable  cases  of  pregnancy, 
it  is  not  that  the  characteristic  signs  are  wanting,  but  the 
practitioners  who  previously  examined  the  patients  have 
failed  to  appreciate  them. 

Two  rules  should  be  observed  in  dealing  with  these 


174  Diseases  of  the  Ovaries. 

cases  of  suspected  pregnancy — (i)  When  in  doubt,  defer 
expressing  an  opinion,  and  see  the  patient  again  after  a 
few  weeks'  interval ;  (2)  N'ever  pass  a  sound  when  the7'e 
is  even  a  suspicion  of  pregfiancy. 

Oestatioii  in  one  horn  of  a  hicornuate  uterus  is  a 
condition  to  bear  in  mind.  Its  lateral  position  may 
cause  it  to  simulate  an  ovarian  tumour ;  more  frequently 
it  has  been  mistaken  for  a  uterine  myoma.  {See  page  362.) 

With  ordinary  care  there  is  little  risk  of  mistaking  a 
case  of  normal  uterine  gestation  for  an  ovarian  tumour ; 
but  there  is  an  abnormal  form  of  pregnancy  occasionally 
mistaken  for  ascites  or  a  large  ovarian  cyst,  it  is  known  as 
Hydraiiinioi^  and  is  due  to  an  excess  of  amniotic  fluid. 
The  amount  of  fluid  within  the  sac  of  the  amnion  at 
birth  varies  in  different  cases,  and  although  it  probably 
rarely  exceeds  some  six  or  eight  ounces,  it  may  amount 
to  forty  ounces  without  being  regarded  as  pathological. 

McClintock*  wrote  an  interesting  account  of  this  con- 
dition under  the  title  of  "  dropsy  of  the  ovum,"  and 
limits  the  term  to  cases  in  which  the  quantity  of  fluid 
exceeds  two  quarts.  The  first  case  he  describes  is  that  of 
"  a  lady,  aged  thirty-three,  in  her  tenth  pregnancy,  who 
enjoyed  good  health  up  to  the  beginning  of  the  seventh 
month  of  utero-gestation.  The  abdomen  then  began  to 
increase  in  a  rapid  manner,  and  in  a  fortnight  attained 
such  proportions  as  to  produce  pain  and  distress.  The 
patient  was  free  from  anasarca,  the  abdomen  was 
immensely  swelled,  tense,  and  obscurely  fluctuating. 
She  was  uneasy  in  any  attitude  or  position. 

"  On  making  an  internal  examination  the  mem- 
branes were  protruding  through  the  os,  extremely  tense, 
and  no  presentation  of  the  foetus  distinguishable.  The 
membranes  were  torn,   '  whereupon  a  volume  of  water 

*  Diseases  of  Women  ;  1863. 


Hydramnios.  1 7  5 

instantly  gushed  out,  and  almost  at  the  same  time  the 
head  of  the  fcetus.  Its  birth  was  retarded  as  much  as 
possible,  but  the  temporary  obstruction  caused  by  the 
child  being  removed,  the  torrent  began  afresh,  filling 
every  available  vessel,  and  deluging  the  bed  and  floor 
within  the  brief  space  of  a  minute  or  two.'  " 

McClintock  mentions  the  fact  that  when  it  affects  a 
woman  with  twins,  "  we  usually  find  that  the  amnios  of 
one  child  only  is  engaged."  This  he  observed  in  eleven 
twin  cases  in  which  the  disease  was  present,  and  further 
points  out  that  in  thirty-three  cases  where  he  particularly 
noted  the  facts,  five  were  first  labours,  eight  were  second 
labours,  one  a  twelfth,  and  the  rest  intermediate. 
Subsequent  observations  indicate  that  this  remarkable 
condition  is  most  frequently  associated  with  twins;  the 
foetus  is  malformed,  hydrocephalus  being  the  most  com- 
mon abnormality ;  it  comes  on  usually  about  the  sixth 
or  seventh  month ;  its  onset  ■  may  be  gradual,  but  more 
frequently  the  fluid  rapidly  accumulates.  Clinically,  it 
presents  all  the  features  of  a  very  large  ovarian  cyst, 
but  may  be. distinguished  from  it  by  the  existence  of  the 
signs  of  pregnancy,  and  ballotte7nent  is  particularly 
distinct. 

It  is  of  importance  to  be  aware  of  this  condition,  for 
it  has  in  several  instances  been  overlooked,  and  the 
uterus  tapped  under  the  supposition  that  it  was  an 
ovarian  cyst ;  abortion  follows  the  tapping,  and  more 
than  one  case  has  terminated  fatally. 

Reeves  *  reported  a  case  in  which  he  opened  an 
abdomen  "to  remove  what  was  supposed  to  be  an  ovarian 
cyst  complicating  pregnancy,  but  discovering  it  to  be  due 
to  hydramnios,  closed  the  incision.  The  uterus  w^as  then 
emptied  through  the  vagina,  and  the  patient  recovered. 

*  Journal  of  the  Brit:  Gyn.  Sac,  vol.  iii.  No.  12,  p.  547. 


176  Diseases  of  the  Ovaries, 

In  this  case  the  foetus  was  hydrocephalic,  and  one  set 
of  membranes  chiefly  affected.  The  patient  was  twenty- 
one  years  of  age  ;  it  was  her  second  pregnancy,  and  had 
advanced  to  the  fifth  month. 

The  following  case,  reported  by  Bantock,*  is  instruc- 
tive in  its  bearing  on  treatment  : — 

"  He  saw  in  consultation  a  woman  thirty-two  years  of 
age,  the  mother  of  five  children.  The  history  given  by 
the  patient  was  that  she  had  been  very  well  until  within 
about  a  week  or  two,  that  she  had  rapidly  increased  in 
that  time,  and  that  she  had  not  menstruated  for  over 
three  months.  The  abdomen  was  very  much  distended, 
there  was  free  fluctuation  over  the  greater  part,  and  the 
legs  were  cedematous.  The  cervix  was  somewhat  soft 
and  the  mammary  areolae  enlarged  and  darkened.  The 
diagnosis  was  a  rapidly  growing  ovarian  tumour,  with 
pregnancy  of  between  three  and  four  months.  Arrange- 
ments were  made  as  quickly  as  possible,  and  he  operated 
on  her  four  days  later,  assisted  by  Dr.  Dingle.  By  that 
time  she  had  still  further  increased  in  size,  and  the 
oedema  had  extended  to  the  hypogastrium.  On  open- 
ing the  abdomen  he  at  once  perceived  that  the  tumour 
was  uterine,  and  not  ovarian,  and  he  concluded  that  he 
had  to  deal  with  a  case  of  hydramnios.  Three  courses 
now  presented  themselves :  viz.  whether  to  close  the 
abdomen  and  induce  premature  labour,  or  to  tap  the 
uterus  with  an  aspirator,  close  the  abdomen,  and  await 
the  issue  of  events,  or  to  remove  the  whole  organ  by 
supra-vaginal  hysterectomy.  He  chose  the  last^  as  offer- 
ing the  best  chance  of  success.  In  opening  the  uterus, 
over  thirteen  pints  of  fluid  were  removed  from  the 
amniotic  sac,  and  a  foetus  came  into  view.  This  was 
extracted    without     dividing     the     cord,   and    another 

*  Journal  of  the  B7-it.  Gyn.  Soc,  vol.  iii.  No.  12,  p.  489. 


Ovarian  Cysts  and  Pregnancy.  177 

was  seen,  but  not  removed.  The  whole  organ  was 
now  turned  out  and  secured,  in  his  usual  way,  along 
with  the  ovaries  by  means  of  a  serre  no^ud.  The  woman 
made  an  excellent  recovery."  In  this  case  I  had  an 
opportunity  of  examining  the  parts.  The  fcetuses  were 
of  about  the  fourth  month  of  gestation,  females,  and 
normally  formed. 

Ovarian  cysis  soiiietiiiies  co-exist  witli  preg^- 
iiaiicy. — A  woman  known  to  have  an  ovarian  tumour  sub- 
sequently becomes  pregnant;  such  a  case  may  give  rise  to 
no  difficulty  in  diagnosis  ;  but  when  a  patient  comes  under 
observation  with  the  two  conditions  co-existing,  we  have 
to  deal  with  a  combination  of  circumstances  that  may 
mislead  the  most  wary.  In  many  cases  the  condition  of 
the  uterus  has  not  been  suspected  until  the  abdomen  was 
opened  to  remove  the  ovarian  tumour,  and  even  then 
the  enlarged  uterus  has  been  mistaken  for  a  cyst,  and 
punctured. 

The  diagnosis  of  an  ovarian  cyst  complicating  preg- 
nancy is  based  upon  the  existence  of  the  signs  of  the 
tumour  plus  those  of  pregnancy.  When  the  tumour  is 
large  the  abdomen  is  more  widened  out  laterally  than  in 
simple  pregnancy,  and  there  is  commonly  a  depression 
between  the  rotundity  presented  by  each  tumour. 

In  many  instances  the  tumour  is  of  moderate  dimen- 
sions, and  becomes  impacted  between  the  gravid  uterus 
and  the  pelvis.  Such  have  been  mistaken  in  the  early 
months  of  gestation  for  retroverted  gravid  uteri. 

All  ovarian  tuuionr  may  co-exist  with  tubal 
pregnancy.— An  example  of  this  rare  combination 
occurred  in  my  own  practice,  and  gave  rise  to  rather 
anomalous  symptoms.  The  following  facts  may  be  briefly 
mentioned  : — 

The  patient  was  twenty-six  years  of  age,  mother  of 
two  children,  the  youngest  being  six  years  old.     She  was 

RI 


lyB  Diseases  of  the  Ovaries. 

suddenly  seized  with  acute  pain  in  the  lower  part  of  the 
belly.  The  attack  of  pain  was  accompanied  by  free 
discharge  of  blood  from  the  vagina.  Menstruation  had 
been  quite  regular. 

On  examining  the  abdomen  no  swelling  could  be 
detected.  The  left  breast  was  slightly  enlarged,  and  milk 
could  be  easily  squeezed  from  it.  There  was  no  difficulty 
with  the  bladder.  On  examining  the  pelvic  viscera  a 
rounded,  movable,  tender  swelling  could  be  made  out  on 
the  left  side  of  the  uterus,  and  a  similar  but  larger  swelling 
on  the  right  side,  but  this  was  not  tender.  The  patient 
was  admitted  to  the  hospital  next  day,  and  Dr.  Boxall 
kindly  saw  the  case  with  me.  He  suspected  that  it  was 
a  retroverted  gravid  uterus.  In  order  to  settle  the  dia- 
gnosis chloroform  was  administered,  and  Dr.  Boxall 
pushed  the  swelling  on  the  left  side  upwards  into  the 
abdomen.  It  was  then  found  to  be  distinct  from  the 
uterus,  which  was  clearly  not  gravid.  In  the  afternoon 
the  patient  complained  of  severe  aching  pain  in  the  back, 
and  had  a  very  thin  pulse,  and  at  six  o'clock  the  tem- 
perature rose  to  103°.  I  opened  the  abdomen  next  day  : 
the  peritoneal  cavity  contained  a  large  quantity  of  blood, 
which  had  escaped  from  the  left  Fallopian  tube,  which 
was  gravid.  On  the  right  side  there  was  an  ovarian  cyst 
as  large  as  an  orange. 

Fliysoiiieti-a,  sometimes  termed  "  emphysema 
uteri,"  is  a  rare  condition,  in  which  the  uterine  cavity  is 
distended  with  gas,  due  to  the  presence  of  decomposing 
substances.  It  might  be  mistaken  for  a  suppurating 
ovarian  cyst  containing  gas.  I  have  never  seen  a  case 
of  physometra,  and  would  refer  the  reader  to  an  exhaus- 
tive paper,  so  far  as  references  are  concerned,  published 
by  Yarrow.*. 

*  Am.  Journal  of  Obsteti,  vol.  xvi.  p.  785. 


Uterixe  Myomata.  179 

morbid  condition  of  the  uterus  other  than 
pregnancy. 

Uterine  iiiyoiiiata  (fibroids)  equal,  if  they  do  not 
excel,  ascites  and  pregnancy  in  simulating  ovarian 
tumours.  Many  of  the  largest  and  heaviest  abdominal 
tumours  grow  from  the  uterus. 

Not  infrequently  a  myoma  grows  from  the  anterior  or 
posterior  wall  of  the  uterus,  and  forms  a  large  peduncu- 
lated, smooth,  movable  tumour,  occupying  the  flank. 
When  such  a  tumour  undergoes  mucoid  softening  and 
forms  a  spurious  cyst — the  so-called  Jibro-cyst  of  the 
uterus — the  signs  of  an  ovarian  cyst  are  well  imitated. 

In  rare  instances  a  myoma  springs  from  the  side  of 
the  uterus  and  pushes  its  way  between  the  layers  of  the 
broad  ligament,  and  then  rising  in  the  abdomen,  forms 
a  mass  which  has  been  known  to  weigh  twenty  pounds 
or  more. 

Large  uterine  myomata  may  co-exist  with  ovarian 
cysts  ;  and  lastly,  an  uterus  with  myomata  in  its  walls  may 
become  gravid.  The  diagnosis  is  still  further  complicated 
by  the  fact  that  myomata  of  large  size  occasionally  arise 
in  the  ovaries,  and  in  order  to  indicate  the  difficulty  which 
sometimes  besets  diagnosis,  tumours  have  been  removed 
and  the  operation  completed  under  the  belief  that  they 
were  ovarian,  but  subsequent  dissection  of  the  parts  has 
shown  that  the  tumours  sprang  from  the  uterus. 

The  age  of  the  patient  sometimes  throws  light  on  the 
case,  as  uterine  myomata  are  excessively  rare  before  the 
twenty-fifth  year,  uncommon  before  the  thirtieth  year, 
but  very  frequent  after  that  period  of  life. 

The  physical  signs  of  large  uterine  myomata  are  in 

some  points   identical   with   those   of  ovarian  tumours. 

As  a  rule,  uterine  tumours   occupy   the   middle  of  the 

abdomen,  but  pedunculated  myomata  will  sometimes  he 

M  2 


i8o  Disease.'^  of  the  Ovaries. 

in  the  flanks,  like  ovarian  tumours.  To  palpation  they 
may  be  perfectly  smooth  ;  frequently  they  are  irregular 
and  tuberose:  this  is  a  valuable  sign.  Uterine,  like 
ovarian,  tumours  are  dull  on  jDercussion ;  the  dulness 
ceases  abruptly  at  the  borders  of  the  tumour,  and  the 
flanks  are  resonant  in  all  positions  of  the  patient. 

Auscultation  is  frequently  valuable  ;  myomata,  espe- 
cially those  which  grow  rapidly,  often  yield  a  loud 
venous  murnmr  when  auscultated.  This  important  aid 
to  diagnosis  is  present  in  about  half  the  cases.  It  has 
been  said  to  occur  occasionally  in  ovarian  tumours.  I 
have,  as  yet,  failed  to  detect  it.  The  murmur  is  syn- 
chronous with  the  pulse  ;  firm  pressure  may  increase  the 
sound,  but  sometimes  obliterate  it.  The  murmur  is 
usually  best  heard  with  an  ordinary  wooden  stethoscope. 
Often  it  is  as  convenient  to  cover  the  abdomen  with  a 
sheet  and  apply  the  ear  alone.  Frequently  the  murmur 
may  be  heard  all  over  the  swelling  j  occasionally  it  is 
limited  in  its  distribution. 

A  pelvic  examination  furnishes  important  information 
in  cases  of  uterine  myoma,  for  the  tumour  will  be  found 
to  have  close  relations  with  the  uterus.  When  the  examin- 
ing finger  is  firmly  fixed  upon  the  cervix  and  the  tumour 
moved  by  the  free  hand,  the  cervix  and  tumour  will 
move  together.  Frequently  the  whole  uterus  and  cervix 
form  a  rounded  globular  mass,  occupying  nearly  the 
whole  available  pelvic  space,  and  in  the  place  of  an 
elongated  cervix  simply  a  dimple  will  be  found  at  the 
top  of  the  vagina,  representing  the  os  uteri. 

Sometimes  the  uterine  sound  will  be  of  assistance. 
In  most  cases  of  myoma  the  cavity  of  the  uterus  is 
elongated,  whilst  in  ovarian  tumour  this  is  rarely  the 
case.  Again,  the  sound  may  give  information  of  the 
position  of  the  tumour  :  whether  it  grows  from  the  fundus, 
front  or  back  of  the  uterus,  or  involves  the  whole  organ. 


Uterine  Mvomata.  i8i 

The  sound  is  an  instrument  that  requires  extreme  care, 
and  it  should  be  remembered  that  a  uterus  with  myomata 
in  its  walls  sometimes  becomes  gravid. 

x\nother  distinguishing  feature  of  myomata  is  nienoi-- 
liiag^ia,  and  this  is  a  very  important  clinical  sign ;  it  is 
rarely  associated  with  ovarian  cysts.  Uterine  myomata 
exist  without  this  accompaniment,  but  when  a  woman 
comes  under  observation  with  a  large  abdominal  tumour, 
and  complains  of  menorrhagia  recurring  at  frequent 
intervals,  and  presents  an  anaemic  appearance,  the  tumour 
in  the  majority  of  cases  is  a  uterine  myoma. 

When  free  haemorrhage  follows  even  the  gentle  use 
of  the  sound,  it  is  often  an  indication  that  there 
is  a  sub-mucous  "  fibroid"  projecting  into  the  uterine 
cavity. 

Ovarian  tumours  rarely  interfere  with  either  the 
bladder  or  rectum,  yet  both  conditions  occur  in  uterine 
tumours.  When  very  large,  they  compress  the  parts  at 
the  pelvic  brim  ;  and  when  of  moderate  dimensions  they 
become  "  locked  "  in  the  pelvic  cavity  and  exert  pressure 
on  the  rectum,  and  compress  the  neck  of  the  bladder, 
leading  to  retention  of  urine.  Hence  pressure  symptoms 
occur  most  frequently  with  myomata  of  moderate  dimen- 
sions restricted  to  the  pelvis. 

When  ovarian  cysts  are  associated  with  a  myoma  of 
the  uterus,  it  is  extremely  difficult  to  decide  whether  the 
second  tumour  is  a  pedunculated  myoma  or  an  ovarian 
cyst.  Some  forms  of  soft  rapidly-growing  myomata  will 
yield  a  false  percussion  wave,  simulating  a  cyst  con- 
taining thick  tenacious  fluid ;  and  a  large  uterine  myoma 
will  still  further  simulate  an  ovarian  cyst  when  it  has 
undergone  extensive  mucoid  softening,  and  forms  what 
is  sometimes  called  a  fibro-cystic  tumour  of  the  uterus. 

In  spite  of  the  most  careful  examination,  it  is  some- 
times impossible  to  decide  between  an  ovarian  tumour  and 


1 82  Diseases  oe  the  Oi'aries, 

a  uterine  myoma ;  under  such  conditions  the  surgeon 
explores  the  parts  through  an  abdominal  incision. 

When  an  ovarian  cyst  and  a  myoma  of  the  uterus  co- 
exist, ovariotomy  should  be  performed,  and  the  second 
ovary,  whether  diseased  or  not,  should  be  removed,  so  as 
to  induce  an  artificial  menopause.  Such  procedure  has 
been  followed  by  the  most  satisfactory  results,  the  uterine 
tumour  disappearing.  In  most  cases  where  ovarian  cysts 
complicate  uterine  myomata,  both  ovaries  will  be  found 
diseased. 

The  museum  of  the  Middlesex  Hospital  contains  a 
portion  of  a  very  large  oophoritic  adenoma,  which  was 
associated  with  a  large  calcified  uterine  myoma. 

When  ovarian  cysts  co-exist  with  uterine  myomata, 
especially  when  both  ovaries  are  cystic,  rotation  of  one 
of  the  cysts  is  very  liable  to  occur. 

Fluid  distensions  of  the  uterus^  such  as  hydro-  o?' 
pyo-metra^  retai?ied  7ue?ises,  and  the  so-called  hydatid 
pTcgnajicy  are  rarely  likely  to  be  confounded  with  ovarian 
tumours.  Retained  fluid  in  one  horn  of  a  bicornuate 
uterus  might  lead  to  difficulty,  and  is  a  possibihty  to 
bear  in  mind. 


i83 


CHAPTER  XVI. 

THE    DIFFERENTIAL    DIAGNOSIS     OF     OVARIAN 
TUMOURS. 

Hydatid  cysts  of  the  liver,  omentum,  and  broad 
ligament  have  often  caused  difficulty  in  the  differential 
diagnosis  of  ovarian  cysts. 

Hydatid  cysts  of  small  size  connected  with  the  liver 
do  not  give  rise  to  difficulty,  but  it  is  when  these  cysts 
attain  large  proportions,  displace  the  viscera,  and  dip  into 
the  pelvis  that  they  simulate  ovarian  cysts.  Hydatid 
cysts  are  rarely  attended  with  pain  or  uneasiness,  and  it 
generally  happens  that  attention  is  first  called  to  them  by 
the  patients  or  their  friends  noticing  the  more  or  less  un- 
symmetrical  swelling  of  the  abdomen.  These  tumours, 
when  they  project  the  surface  of  the  abdomen,  appear  as 
rounded,  tense,  elastic  swellings,  free  from  pain  or  tender- 
ness when  uninflamed.  They  fluctuate  distinctly,  and  a 
peculiar  sign — the  hydatid  fj-emitus — can  sometimes  be 
obtained  by  placing  the  palm  of  the  left  hand  upon  the 
tumour  and  sharply  percussing  with  the  fingers  of  the 
right ;  it  is  a  peculiar  tremor  or  thrill,  only  felt  over  a 
hydatid  cyst.  The  sign  is  rarely  obtained  satisfactorily. 
Hydatid  cysts  sometimes  suppurate,  and  then  all  the 
signs  indicative  of  an  abscess  are  present.  Perhaps  the 
best  method  of  obtaining  a  correct  diagnosis  is  to  aspirate 
the  cyst ;  the  character  of  the  fluid  quickly  settles  the 
question,  for  it  is  non-albuminous,  clear,  probably  con- 
tains scolices,  or  hooklets,  and  chloride  of  sodium.     It 


184  Diseases  of  the  Ovaries. 

is  neutral  or  slightly  alkaline ;  specific  gravity  varies  from 
1,008  to  1,013.  Often  fragments  of  the  characteristic 
laminated  lining  of  the  cyst  will  come  away.  A  large 
hydatid  cyst  of  the  liver  may  co-exist  with  similar  cysts 
in  the  omentum,  the  omental  cysts  varying  in  size  from 
a  walnut  to  an  orange.  Multiple  cysts  sometimes  give 
rise  to  the  suspicion  of  malignant  disease. 

When  one  or  more  large  hydatid  cysts  are  connected 
with  the  omentum,  and  dip  into  the  pelvis,  it  is  not 
always  easy  to  form  a  correct  diagnosis,  especially  when 
we  remember  that  ovarian  cysts  of  small  size  may  adhere 
to  the  omentum,  and  their  uterine  or  broad  ligament 
attachments  become  slowly  sundered. 

Primary  hydatid  cysts  of  the  ovary  are  unknown. 
The  museum  of  St.  Bartholomew's  Hospital  contains  a 
specimen  thus  described  in  the  catalogue  : — 

"Part  of  a  large  cyst  connected  with  the  ovary,  and 
the  membranes  of  some  hydatids  which  it  contained. 
The  greater  part  of  the  cyst  is  composed  of  a  tough 
fibrous  tissue,  but  portions  of  its  walls  are  as  hard  as 
cartilage,  and  have  small  plates  of  bone-like  substance  in 
them."  In  addition,  the  woman  from  whom  this 
specimen  was  taken  had  hydatid  cysts  within  the  ilium, 
the  walls  of  the  bone  being  expanded  so  as  to  form  a 
large  cavity,  which  extended  into  the  sacrum,  spinal  canal, 
and  acetabulum.  The  patient  was  an  elderly  woman, 
who  died  in  consequence  of  the  suppuration  of  some  of 
the  cysts.     The  disease  was  of  long  standing. 

It  is  impossible  to  decide  from  an  examination  of 
the  specimen  whether  this  was  a  hydatid  cyst  of  the 
ovary  or  a  cyst  adherent  to  the  ovary.  An  extensive 
search  through  periodical  and  special  literature,  and  an 
examination  of  the  museums  of  pathology,  enable  me 
to  state  that  there  is  no  instance  known  of  a  hydatid  cyst 
commencing  in  the  ovary;  the  few  specimens  reported 


Hydatids  of  the  Liver.  185 

as    such   originated    in   the    near   neighbourhood,    and 
involved  the  ovary  by  extension. 

Hydatid  cysts  of  the  hver  occasionally  attain  such 
large  proportions  as  to  reach  and  even  occupy  the  pelvis. 
Bryant*  has  recorded  an  instructive  example  of  this.  A 
woman  thirty-five  years  of  age  was  admitted  into  Guy's 
Hospital  in  1868,  under  the  care  of  Dr.  Oldham,  with  an 
abdominal  tumour,  which  had  been  slowly  growmg  for 
fourteen  years.  In  1861  Oldham,  under  the  impression 
that  the  cyst  was  ovarian,  tapped  it,  and  drew  off 
seven  pints  of  fluid.  The  cyst  re-filled,  and  continued 
to  increase  in  size  until  her  condition  rendered  it  neces- 
sary to  resort  to  some  effectual  mode  of  treatment.  The 
physical  signs  presented  by  the  cyst  did  not  quite  accord 
with  an  ovarian  tumour.  "  On  kneading  the  mass  with 
the  hand  on  either  side,  a  peculiar  doughy  sensation  was 
felt,  unlike  what  is  usually  present  in  ovarian  disease,  but 
yet  unlike  what  is  usually  felt  in  a  hydatid  cyst." 

When  the  abdomen  was  opened  and  the  cyst  punctured, 
it  was  ascertained  to  be  a  hydatid  cyst  full  of  vesicles, 
and  Bryant  believed  that  the  peculiar  physical  sign 
described  above  "was  clearly  due  to  the  rolling  and 
pressing  together  of  the  immense  closely-packed  mass  of 
hydatid  cysts  that  the  parent  tumour  contained.'' 

The  precise  origin  of  this  cyst  was  never  accurately 
ascertained,  as  the  patient  recovered. 

Hydatid  cysts  may  grow  immediately  beneath  the 
pelvic  peritoneum,  between  the  layers  of  the  broad 
ligament,  or  confined  to  the  subserous  tissue  of  the 
uterus.  In  such  situations  it  is  impossible  to  frame 
precise  rules  for  diagnosis. 

Hydatid  cysts  growing  in  the  subserous  tissue  of  the 
uterus  are  very  rare.     Dr.  A.  A.  Altormyan,  of  Aleppo, 

*  Guy  s  Hospital  Reports,  vol.  xiv.  p.  235. 


1 86  Diseases  of  the  Oi'aries. 

North  Syria,  has  described  an  unusual  case.  A  married 
woman,  thirty-five  years  of  age,  came  under  his  care, 
complaining  of  a  tumour  in  the  abdomen.  On  examina- 
tion, a  rounded  freely  movable  tumour  about  the  size  of 
the  head  was  found.  It  did  not  appear  to  be  connected  with 
the  uterus,  and  was  thought  to  be  ovarian ;  operation  was 
advised.  Four  months  later  the  patient  returned.  The 
tumour  was  now  twice  as  large  as  at  the  first  examination; 
it  was  painful,  and  fixed  in  a  more  central  position.  She 
now  consented  to  its  removal. 

When  the  abdomen  was  opened  the  tumour  was  found 
fixed  by  a  few  easily  separable  adhesions.  The  trocar 
drew  off  some  light  straw-coloured  fluid.  The'  pedicle 
originated  in  the-  substance  of  the  uterus.  An  elastic 
ligature  was  passed  around  it,  and  the  stump  treated  by 
the  extra-peritoneal  method.  The  tumour  had  a  thick 
capsule  formed  from  the  fundus  of  the  uterus,  just  above 
the  attachment  of  the  left  Fallopian  tube.  Within  the 
uterine  capsule  was  found  a  thick,  laminated,  homo- 
geneous elastic  membrane,  displaying  a  highly  peculiar 
tremulous  motion.  The  cyst  contained  about  a  dozen 
hydatid  vesicles  and  some  granular  particles.  Hooklets 
and  buds  from  the  lining  membrane  were  detected  by 
the  microscope.     The  woman  made  a  good  recovery.* 

Hydatid  cysts  grow  in  the  pelvic  connective  tissue, 
and  attain  very  large  dimensions  ;  they  may  be  associated 
with  hydatid  disease  of  other  abdominal  viscera  or  be 
confined  to  the  pelvis.  In  most  cases  such  cysts  contain 
echinococcus  colonies  ;  occasionally  they  are  sterile,  then 
the  true  nature  of  the  case  is  liable  to  be  overlooked. 

Hydatid  cysts  of  the  pelvis  have  been  carefully,  studied 
by    Freund,t   and    his    cases    are    illustrated    by    some 


*  La?icet,  1 891,  vol,  i.  p.  769. 

Gynixkologische  Klinik,  Strassbuig,  1885,  Bd.  i. 


Fel'i'ic  Hydatids. 


187 


admirable  diagrams  and  drawings.  He  briefly  relates  a 
case  which  occurred  in  an  unmarried  woman,  forty-five 
years  of  age,  who  came  under  his  care  in  a  very  exhausted 
and  wasted  condition.  She  was  suffering  from  a  remittent 
form  of  fever,  and  had  for  several  years  complained   of 


Fig.  59. — Hydatid  Cj'St  in  the  Pelvis.     (After  Freund. 
R,  Rectum  ;  V,  uterus  ;  B,  bladder. 


increasing  difficulty  in  micturition  and  -defaecation.  For 
some  months  there  had  been  pain  in  the  pelvis,  paralysis, 
and  oedema  of  the  right  leg. 

A  tumour  was  detected  on  the  right  side  of  the  pelvis, 
displacing  the  adjacent  viscera;  fluctuation  was  also 
detected  over  the  right  sciatic  notch.  This  swelling  was 
punctured  with  a  trocar,  and  some  foul-smelling  fluid 
escaped.  Eventually,  a  section  through  the  pelvis 
revealed    a    suppurating    echinococcus    colony    in    the 


1 88  Diseases  of  the  Ovaries. 

connective  tissue  of  the  right  side  of  the  pelvis,  which 
had  burrowed  through  the  great  sciatic  notch  into  the 
buttock  (Fig.  59). 

The  section  represented  in  the  coloured  drawing, 
Plate  III.,  is  also  from  a  case  by  Freund.  The  patient 
was  a  badly-nourished  girl,  twenty-two  years  of  age,  whose 
subserous  tissues  seemed  to  have  been  subject  to  a 
general  invasion  of  these  parasites  ;  they  were  found  in 
the  liver,  spleen,  omentum,  pelvic  connective  tissue,  and 
in  the  meso-colon.  The  relation  of  the  echinococcus 
colonies  to  the  subserous  tissue  of  the  broad  ligament 
was  admirably  shown  in  sagittal  sections  of  the  pelvis. 

Hydatid  cysts  of  the  pelvis  sometimes  discharge 
themselves  into  the  rectum,  vagina,  or  bladder ;  and 
Freund  details  one  case  in  which  the  vesicles  escaped  at 
various  times  by  each  of  these  passages  in  the  same 
patient. 

When  the  characteristic  vesicles,  membranes,  or  hook- 
lets  escape  either  spontaneously  or  secondary  to  puncture 
of  a  cyst,  the  diagnosis  is  simple.  The  difficulty  is  in 
recognising  sterile  or  barren  hydatid  cysts,  especially 
when  large. 

Cullingworth^  has  recorded  the  following  case  : — A 
woman  twenty-three  years  of  age  came  under  his  care 
for  an  abdominal  swelling  which  she  had  noticed  five 
months  previously  ;  she  believed  herself  pregnant.  She 
had  had  one  child.,  and  nienstruatmi  cotitinned  through 
thepregnaiicy.  Since  she  noticed  the  abdomen  increasing 
in.  size,  menstruation  had  continued  regularly,  but,  re- 
membering her  previous  experience,  she  attached  no 
importance  to  this  sign. 

The  swelling  was  somewhat  globular^  and  extended 
from  the  pubes  to  a  line  midway  between  the  umbilicus 

*   Tra?is.  Obsiet.  Soc,  Ltmdo?!,  vol.  xxx.  p.  202. 


JPeriL  oneum 


:^^H;-iiiir(j'te|   JS c7iinococcus  Colony 


Plate    III.— Hydatids    burrowing  under  the  Serous  Covering  of  the  Uterus. 

(After  Freund.) 


Sterile  Hydatid  Cysts.  189 

and  ensiform  cartilage ;  fluctuation  could  be  distinctly 
felt  ;  there  was  a  bruit,  synchronous  with  the  pulse, 
especially  distinct  in  the  left  iliac  region.  One  morning, 
whilst  sitting  up  in  bed,  she  was  seized  with  severe 
abdominal  pain,  and  the  abdomen,  which  had  been  very 
tense,  became  suddenly  soft.  A  few  weeks  later  the 
abdomen  was  again  distended,  but  this  time  with  ascitic 
fluid.  The  abdomen  was  opened,  and  six  pints  of  ascitic 
fluid  evacuated ;  the  uterus,  or  what  appeared  to  be  the 
uterus,  was  enlarged  to  the  size  usual  at  the  fifth  month 
of  pregnancy.  Nothing  like  a  ruptured  cyst  was  dis- 
covered, or  anything  to  explain  the  sudden  collapse.  She 
died  eleven  days  after  the  operation.  x\t  the  autopsy  the 
uterus  was  found  to  be  normal  in  size,  and  w;hat  had 
appeared  to  be  the  uterus  was  a  thick-walled  sac,  with 
the  uterus  embedded  in  its  anterior  wall.  "  On  section, 
a  quantity  of  thick,  opalescent,  jelly-like  fluid  escaped,  in 
which  were  portions  of  tissue  like  parchment.  No  foetal 
remains  were  found.  The  inner  surface  of  the  cyst  wall 
was  white  and  smooth."  The  specimen  was  submitted 
to  a  committee,  which  made  a  long  report.  The  cyst  had 
completely  separated  the  folds  of  the  left,  and  burrowed 
into  the  lower  part  of  the  right  broad  ligament.  The 
cyst  wall  had  an  outer  fibrous  coat,  a  middle  layer  of 
w'ell-developed  plain  muscle  fibres,  and  an  inner  coat  of 
connective  tissue.  The  committee  expressed  no  opinion 
as  to  the  character  of  this  cyst,  but  the  clinical,  anatomical, 
and  histological  details,  though  mainly  negative,  are 
sufficient  to  lead  me  to  believe  that  this  was  a  degenerate 
or  sterile  hydatid  cyst  of  the  broad  ligament. 

The  occurrence  of  suppuration  in  sub-peritoneal  pelvic 
hydatids  is  due  to  the  fact  that  such  cysts  encroach  upon 
mucous  canals,  such  as  the  rectum,  vagina,  or  intestine, 
and  this  allows  intestinal  gases  to  invade  the  cyst,  and 
produce  decomposition. 


190  Diseases  of  the  Ovaries. 

The  peculiar  and  rare  variety  of  echinococcus  disease 
known  as  multilocular  hydatids  has  not  yet  been  reported 
in  the  neighbourhood  of  the  uterus  or  ovary. 

British  hterature  contains  very  scanty  records  of  pelvic 
hydatids.  Freund's  unique  experience  is  attributed  to 
the  fact  that  his  observations  were  made  in  Silesia — a 
European  region  second  only  to  Iceland  in  the  frequency 
with  which  hydatids  affect  the  inhabitants.  Australian 
surgeons  ought  to  be  able  to  add  to  our  knowledge  of 
pelvic  hydatids  in  women. 

Abnormal  conditions  of  the  kidneys  have  frequently 
been  mistaken  for  ovarian  tumours,  but  since  surgical 
diseases  of  the  kidneys  have  been  more  thoroughly 
investigated,  renal  tumours  are  less  likely  to  be  con- 
founded by  surgeons  with  those  of  the  ovaries. 

The  conditions  which  have  been  confounded  with  ova- 
rian tumours  are  misplaced  kidney,  single  kidney,  hydro- 
nephrosis, renal  tumour,  and  congenital  cystic  kidney. 

The  kidney  does  not  always  occupy  the  hollow  of  the 
loin  ;  sometimes  it  is  furnished  with  a  long  pedicle,  which 
enables  it  to  freely  move  about  the  abdomen  ;  under  such 
conditions  it  may  be  mistaken  for  an  ovarian  cyst  with  a 
long  pedicle. 

Less  frequently,  one  of  the  kidneys  may  lie  on  the 
sacro-iliac  synchondrosis,  or  even  occupy  the  hollow  of 
the  sacrum.  An  example  of  the  latter  misplacement  is 
represented  in  Fig.  60.  When  the  kidney  occupies 
abnormal  positions  of  this  kind,  it  always  lies  behind  the 
peritoneum.  It  is  conceivable  that  a  kidney  occupying 
the  hollow  of  the  sacrum  or  the  sacro-iliac  synchondrosis 
might  be  mistaken  for  a  tumour,  if  pelvic  symptoms 
should  lead  to  an  internal  examination. 

Mydro7ieph7'osis  and  pyonephrosis  have  been  mistaken 
for  ovarian  cysts.  Such  errors  are  sometimes  inevitable, 
for  ovarian  cysts  with   long  pedicles  sometimes  occupy 


^ENA  L    TUMO  UR  S. 


191 


the  loins^  and  cystic  kidneys  sometimes  extend  into  the 
false  pelvis.  Hydronephrosis  sometimes  co-exists  with, 
and  is  caused  by  ovarian  tumours. 


Fig.  60. — Kidney  occupying  the  Hollow  of  the  Sacrum. 
A,  Artery  ;  \'.  vein  ;  U,  ureter, 

The  physical  signs  of  renal  tumours  are  very  character- 
istic. There  is  a  swelling  in  one  or  both  loins,  which 
yields  a  dull  sound  on  percussion,  but  as  both  kidneys 
have   the  colon   crossing  in  front  of  them,  an  area  of 


192  Diseases  of  the  Ovaries. 

resonance  is  usually  present  when  they  are  percussed 
from  the  front.  It  is  exceptional  for  an  ovarian  cyst  to 
have  intestine  in  front  of  it,  but  this  may  happen  when 
the  cyst  is  small  and  does  not  displace  the  bowel,  and 
when  adhesions  form  between  a  coil  of  intestine  and  the 
front  surface  of  the  tumour. 

In  addition  to  these  signs,  an  examination  of  the  urine 
furnishes  valuable  evidence,  as  it  may  be  scanty  in 
amount,  and  contain  blood,  pus,  mucus,  or  furnish  other 
evidence  of  renal  disease  sufficient  to  afford  the  prac- 
titioner valuable  indications  of  the  nature  of  the  swelling. 
Another  symptom,  which  is  sometimes  valuable,  is  that 
in  cases  of  hydronephrosis  the  tumour  may  intermit,  the 
intermittence  being  known  by  diminution  in  the  size  of 
the  tumour,  accompanied  by  an  abundant  flow  of  urine. 
This  condition  is  not  so  valuable  as  it  would  at  first  sight 
appear,  because  one  variety  of  ovarian  cyst  intermits, 
viz.  ovarian  hydrocele,  and  an  intermitting  renal  cyst  is 
simulated  by  rupture  of  an  ovarian  cyst,  followed  by 
diuresis. 

An  admirable  account  of  all  that  relates  to  the 
differential  diagnosis  of  renal  tumours  will  be  found  in 
Henry  Morris's  well-known  work  on  the  Surgical  Diseases 
of  the  Kidney. 

A  curious  instance  of  the  difficulty  of  diagnosis  is  the 
following,  recorded  by  Mr.  Lawson  Tait  : — * 

A  patient  had  been  seen  by  Sir  Spencer  Wells,  who 
diagnosed  fibroid  tumour  of  the  uterus ;  and  by  a  dis- 
tinguished London  physician,  who  remarked  that  he  did 
not  think  there  was  anything  very  much  the  matter.  Dr. 
Milner  Moore,  of  Coventry,  was  called  in,  and  diagnosed 
a  suppurating  ovarian  tumour.  Mr.  Tait  saw  the  patient, 
in  consultation  with  Dr.  Moore,  and  confirmed  his  view, 

*  Journal  oj  the  Brit ^  Gyii.  Soc,  vol.  ii.  p.  284. 


Wandering  Spleen.  193 

with  the  extension  that  he  beheved  the  suppuration  was 
due  to  strangulation  and  axial  rotation.  During  the 
operation  the  tumour  was  found  to  be  a  suppurating  cyst 
of  the  left  kidney. 

Ovarian  cyst  and  hydronephrosis  of  one  or  both 
kidneys  may  co-exist.  In  such  cases  the  pressure  of  the 
cyst  causes  distension  of  the  kidney.  In  such  conditions 
the  obvious  treatment  would  be  removal  of  the  ovarian 
tumour. 

Spleen. — When  of  natural  size  this  organ  compli- 
cates the  diagnosis  of  ovarian  tumours  only  when  it  is 
misplaced. 

Wilks  and  Moxon*  write  : — "  We  have  found  a 
spleen,  of  twenty-four  ounces'  weight,  entirely  dislocated 
and  lying  in  the  pelvis,  forming  a  tumour  which  might 
easily  have  been  mistaken  for  ovarian." 

W^hen  this  organ  is  very  movable  it  has  been  termed 
Avaiideriiig'  spleen.  Rokitansky,t  in  an  interesting, 
but  in  England  very  inaccessible  publication,  has  de- 
scribed some  examples  of  this.  In  one  instance  he 
found  a  spleen,  which  had  undergone  axial  rotation  and 
strangulation  of  its  vessels,  adherent  to  the  entrance  of 
the  pelvis. 

In  some  cases  of  partial  transposition  of  viscera  the 
spleen  is  much  displaced.  The  spleen  is  very  loyal  to 
the  stomachy  for  although  the  liver  occupies  the  left 
hypochondrium,  the  stomach  may  not  be  transposed ; 
under  such  conditions  the  spleen  still  retains  its  relation 
to  the  great  cul-de-sac^  and  with  the  stomach  is  much 
depressed  in  the  abdomen,  sometimes  lying  in  the  left 
iliac  region.  In  such  circumstances  it  may  become  a 
clinical  puzzle.  Whenever  the  stomach  is  transposed 
the  spleen  accompanies  it. 

*  Pathological  Anatomy,  p.  472  ;   1875. 

+  Zeitschrift  der  K.  K.  Gcsellschaft  der  Aerzte,   Wicn,  i86o,- Nr.  iii. 

N 


194  Diseases  of  the  Oi^aries. 

An  eiilarg-ed  spleen  has  been  mistaken  in  several 
instances  for  an  ovarian  tumour.  When  enlarged,  the 
spleen  forms  a  tumour,  extending  from  the  left  hypo- 
chondrium  obliquely  downwards  to  the  umbilicus,  and  as 
far  as  the  pelvis  when  very  large.  It  gives  rise  to  dulness 
on  percussion,  moves  up  and  down  with  the  diaphragm 
in  respiration,  lies  in  front  of  the  colon,  and  presents  a 
characteristically  notched  border. 

I^aiicreatic  cysts  may  occasionally  attain  large 
proportions,  but  even  when  of  very  large  size  a  cyst  of 
the  pancreas  is  rarely  likely  to  be  confounded  with  an 
ovarian  cyst. 

Fatty  tiianours  connected  with  the  omentum  or 
subserous  tissue  attain  an  .enormous  size,  and  although 
they  ought  not  to  be  mistaken  for  ovarian  cysts,  are 
frequently  very  puzzling. 

Sir  Spencer  Wells*  has  briefly  recorded  an  attempt  he 
made  to  remove  one,  but  the  patient  died.  The  portion 
of  tumour  which  he  removed  weighed  twenty  pounds. 
It  appeared  to  have  originated  in  the  mesentery. 

Mr.  Meredith!  successfully  removed  an  omental 
lipoma  from  a  woman  sixty-two  years  of  age.  It  weighed 
fifteen  pounds  and  a  half  The  tumour  was  supposed  to 
be  ovarian,  and  it  was  with  this  view  that  its  removal  was 
undertaken. 

It  seems  difficult  to  believe  that  the  gall-bladder 
could  possibly  give  rise  to  error  in  the  diagnosis  of 
ovarian  cysts.  Yet  Lawson  Tait|  relates  a  case  in 
which  a  woman  forty  years  of  age  came  under  his  care 
with  an  abdominal  tumour,  which  presented  the  physical 
signs  of  a  parovarian  cyst.     He  performed  abdominal 

*  Ovarian  and  Uterine  Ttimours  ;   1882. 

t  Trans.   Clin.  Soc,  vol.  xX.    p.   206.       See  also  Homan's  Infer- 
national  JoH!  nal  of  Med.  Sci.,  April,  1891. 
X  Edin.  Med.  Journal,  Oct.,  1889,  p.  315. 


Chyle  Cysts.  195 

section,  making  an  incision  two  inches  long  in  the  middle 
line  below  the  umbilicus,  and  writes: — "On  emptying 
the  tumour,  I  found,  to  my  amazement,  that  it  was  a  gall- 
bladder enormously  distended."  On  exploring  the  cyst, 
"  a  gall-stone  as  large  as  a  filbert-nut  impacted  in  the 
neck  of  the  gall-bladder  was  found."  Two  or  three 
smaller  gall-stones  were  found  in  the  cavity  of  the  cyst. 
The  edges  of  the  opening  in  the  gall-bladder  were 
stitched  to  the  abdominal  wound.  Bile  began  to  flow 
from  the  wound  on  the  morning  of  the  third  day  after 
the  operation.  The  patient  recovered.  The  fluid  con- 
tents from  the  cyst  measured  nearly  eleven  pints,  and 
consisted  of  clear  gluey  fluid. 

The  liver,  when  enlarged,  has  been  found  to  dip 
into  the  pelvis,  and  cause  error  in  diagnosis  ;  and  Mr. 
Thornton  writes  that  Sir  Spencer  Wells  once  explored  an 
abdomen,  expecting  to  find  an  ovarian  cyst,  but  it  was  a 
liver  enlarged  from  cystic  disease. 

Chylous  cyst  of  the  mesentery  has  been  mistaken 
for  an  ovarian  or  parovarian  cyst.  An  interesting  instance 
of  this  was  communicated  to  the  Obstetrical  Society, 
London,  by  Dr.  Adolph  Rasch.*  The  patient  was  a 
Jewess,  twenty-one  years  of  age.  A  large  roundish  elastic 
swelling  occupied  mainly  the  left  side  of  the  abdomen. 
The  rounded  top  of  the  swelling  was  about  two  inches 
above  the  horizontal  umbilical  line.  AVhen  the  abdomen 
was  opened  the  appearance  of  the  tumour  at  once  struck 
all  present ;  it  w^as  of  a  pale  pink  and  very  glossy,  unlike 
any  cyst  he  had  seen  before.  No  adhesions  could  be  felt 
anywhere.  On  piercing  it  with  a  large  trocar,  a  perfectly 
milk-like  fluid  squirted  out  with  great  force ;  little  entered 
the  peritoneal  cavity.  On  drawing  the  w^alls  of  the  cyst 
gently  out,  it  became  evident  that  what  appeared  to  be 

*  Trans.  Obstet.  Soc,  vol.  xxxi.  p.  311.     • 
N    2 


196  Diseases  of  the  Ovaries. 

a  cyst  was  the  two  layers  of  the  mesentery  separated  from 
each  other  by  the  milk-like  fluid.  The  small  intestine,  of 
perfectly  natural  appearance,  was  connected  with  the 
mesentery  in  the  usual  way.  The  hand  inside  came 
down  to  the  region  of  the  spine  at  the  usual  insertion 
of  the  mesentery.  The  inside  of  the  cyst  was  intensely 
congested,  looking  dark  red,  and  freely  oozing.  The 
edges  of  the  cyst  were  stitched  to  the  skin  wound ;  the 
patient  recovered. 

Cysts  similar  to  this  have  been  reported  by  Berg- 
mann,*  Mendes  de  Leon,t  and  Fetherston.| 

Dr.  Carter§  has  published  an  account  of  a  cyst  which 
formed  in  the  mesentery.  Before  operation  it  was  re- 
garded as  an  ovarian  tumour.  It  contained  sixteen  pints 
of  fluid,  judging  from  the  account  of  the  case  it  seems 
very  probable  that  it  was  a  sterile  hydatid  cyst. 

Cysts  of  the  gresit  ©MieiitMna  sometimes  simulate 
ovarian  cysts.  It  has  already  been  pointed  out  that 
ovarian  cysts,  especially  dermoids,  may  become  detached 
from  their  uterine  connections,  and  acquire  adhesions  to 
the  great  omentum,  such  connections  being  sufficient  in 
many  instances  to  preserve  their  vitalit5^  The  omentum 
is  a  very  favourable  situation  for  hydatid  cysts.  They 
rarely  complicate  the  diagnosis  of  ovarian  cysts,  because, 
as  a  rule,  omental  hydatids  are  multiple,  and  are  much 
more  likely  to  be  confounded  with  secondary  deposits  of 
cancer. 

Doran  ||  has  reported  an  omental  cyst  which  had 
been  tapped  several  times  by  Mr,  Goodall-Copestake, 
under  the  impression  that  it  was  ovarian.     Dr.  Bantock 

*  Arcli.  Jiir  Klin.  Chir.  (von  Langenbeck),  1887,  s.  201. 

f  Am.  Journal  of  Obstct.,  vol.  xxiv.  p,  168. 

X  Australian  Med.  Journal,  1890,  p.  475. 

\  British  Med.  Journal,  1883,  vol.  i.  p.  7. 

II    Trans.  Ohstet.  Soc,  I^ondon,  vol.  xxiii.  p.  164. 


Tumours  of  the  Sacrum.  197 

removed  it  from  between  the  layers  of  the  great  omentum 
below  the  transverse  colon.  The  cyst,  which  contained 
many  pints  of  dark  serous  fluid,  is  preserved  in  the 
museum  of  the  Royal  College  of  Surgeons.  The  woman 
was  fifty-eight  years  of  age,  and  had  suffered  from  the 
tumour  many  years.  The  cyst  is  a  very  remarkable  one, 
and,  as  far  as  it  is  safe  to  hazard  an  opinion,  I  think  it 
may  have  been  a  sterile  hydatid  cyst.  In  the  original 
account  of  the  case  a  diagram  is  added  to  indicate  the 
anatomical  relations  of  the  cyst  and  omentum. 

Gooding*  has  published  an  account  of  a  similar 
omental  cyst. 

Tiinioiirs  ill  the  liollo^v  of  tlie  sacrum,  l>e- 
liiud  the  peritoiieiim. — It  has  already  been  pointed 
out  that  a  normal  kidney  may  be  so  abnormally  placed 
as  to  occupy  the  hollow  of  the  sacrum,  lying,  of  course, 
behind  the  pelvic  peritoneum  ;  such  kidneys,  especially 
when  cystic,  may  be  easily  mistaken  in  the  course  of  an 
examination  of  the  pelvic  viscera  for  a  tumour.  Such 
errors  have  arisen. 

There  are  three  morbid  conditions  connected  with 
this  region  which  may  be  confounded,  unless  care  is 
exercised,  with  ovarian  tumours. 

Perhaps  the  most  unusual  case  is  that  recorded  by 
Emmet,  t  An  unmarried  woman,  thirty-six  years  of  age, 
came  under  his  care  with  a  large,  soft,  fluctuating  tumour, 
situated  behind  the  rectum,  and  filling  up  the  hollow  of 
the  sacrum.  The  woman,  when  admitted  to  the  hospital, 
was  supposed  to  be  suffering  from  an  ovarian  tumour,  but 
eventually  Dr.  Emmet  became  impressed  with  the  idea 
that  it  was  "  a  cyst  of  the  right  kidney,  which  had  by 
some  means  become  adherent  to  the  sacrum."  Even- 
tually it  was  aspirated  through  the  rectum,  and  an  ounce 

*  Lancet,  Feb.  12th,  1887,  p.  311. 

t  Am.  Journal  of  Obstet.,  vol.  iii.  p.  623. 


igS  Diseases  oe  the  Ovaries. 

or  more  of  limpid  serous  fluid  withdrawn.  The  patient 
died  comatose  seven  days  later.  At  the  post  mortem 
examination  a  cyst  containing  three  quarts  of  fluid  was 
found  occupying  the  pelvis,  and  extending  upwards  to 
the  second  lumbar  vertebra.  An  examination  of  the 
sacrum  rendered  it  possible  that  the  cyst  was  the  sac  of  a 
spi?ia  bifida  which  communicated  with  the  cavity  of  the 
dura  mater  by  a  funnel-shaped  opening,  caused  by  a 
deficiency  of  about  half  of  the  three  lower  bones  of  the 
sacrum  on  the  right  side.  It  is  much  to  be  regretted 
that  this  very  unusual  case  was  not  dissected  with  more 
skill  and  care. 

Mr.  Frederick  Page*  has  recorded  the  facts  of  a  case 
in  which  a  very  large  non-ovarian  dermoid  was  situated 
behind  the  rectum  and  peritoneum,  in  the  hollow  of  the 
sacrum.  The  patient,  a  woman  forty-seven  years  of  age, 
was  admitted  into  the  Royal  Infirmary,  Newcastle-on- 
Tyne,  supposed  to  be  suffering  from  an  ovarian  tumour. 
On  examining  the  patient  a  large  swelling  could  be  made 
out  extending  as  high  as  the  umbilicus.  It  dipped  deeply 
into  the  pelvis,  and  pushed  the  rectum  and  vagina  for- 
ward, at  the  same  time  compressing  them.  In  order  to 
ascertain  the  nature  of  the  swelling  an  aspirating  needle 
was  introduced  into  it  through  the  rectum ;  sebaceous 
material  and  a  hair  were  withdrawn.  This  made  it 
evident  that  the  tumour  was  a  dermoid.  In  consequence 
of  the  aspiration  inflammatory  complications  ensued, 
rendering  it  desirable  to  remove  the  tumour,  if  possible. 
The  woman  was  placed  in  the  lithotomy  position,  and  a 
semilunar  incision,  six  inches  long,  was  made  across  the 
perineum,  its  centre  corresponding  to  a  point  midway 
between  the  anus  and  the  coccyx,  and  deepened  till  the 
cyst  was  opened,  when  at  once  the  contents  began  to 

*  Brit.  Med.  Jour?ial,  Feb.  21st,  1891,  p.  406. 


F^.CAL  Accumulations.  199 

exude.  Pressure  over  the  abdomen,  by  squeezing  out 
the  thick,  putty-Uke  material,  mixed  with  hair,  with  which 
it  was  filled,  rapidly  reduced  the  size  of  the  tumour,  and 
it  was  emptied  with  a  table-spoon.  By  seizing  the  margin 
of  the  cyst,  and  passing  the  hand  upwards  between  it  and 
the  tissues,  it  was  readily  enucleated  and  withdrawn.  To 
do  this,  all  the  hand  and  the  greater  part  of  the  forearm 
were  buried  in  the  wound.  Large  drainage-tubes  were 
introduced,  and  the  wound  was  closed  with  sutures. 
The  patient  made  an  excellent  recovery. 

The  cyst,  with  its  contents,  weighed  three  pounds, 
and  numerous  hairs  sprang  from  its  inner  surface.  In 
the  dried  condition,  stuffed,  its  circumference  in  one 
direction  was  29 J  inches,  in  the  other  17I  inches.  It 
had  no  pedicle. 

Mr.  Page  was  good  enough  to  let  me  examine  this 
tumour ;  it  is  the  largest  specimen  of  post-rectal  dermoid 
that  has  come  under  my  observation.  Dermoids  in  this 
situation  rarely  exceed  an  orange  in  size. 

Bony  tumoiirs  and  sarcomata,  springing  from 
the  ventral  aspect  of  the  sacrum,  are  not  likely  to  be 
mistaken  for  ovarian  tumours.  I  know  of  no  instance 
in  which  it  has  happened. 

A  distended  bladder  has  been  mistaken  for  an 
abdominal  tumour,  and  even  tapped.  But  it  is  difficult  to 
understand  how  such  an  error  arose.  The  pecuKar  pyriform 
outline  of  the  swelling  formed  by  an  over-full  bladder, 
sometimes  extending  as  high  as  the  umbilicus,  is  very 
characteristic.  Extreme  distension  of  the  bladder  is  of 
frequent  occurrence  in  uterine  tumours,  especially  fibroids, 
in  pelvic  tumours,  and  in  retroversion  of  the  gravid 
uterus.  Under  the  last-mentioned  condition  the  bladder 
has  been  reported  to  have  held  nine  pints  of  urine. 

FsEcal  accumulations,  or,  as  they  are  sometimes 
called,  fsecal  tumours,  occur  most  frequently  in  the 


200  Diseases  of  the  Ovaries. 

colon  and  sigmoid  flexure ;  as  these  parts  have  fre- 
quently a  long  meso-colon,  the  transverse  colon,  when 
U-shaped,  may  touch  the  pubes  ;  faecal  tumours  may 
occupy  any  part  of  the  abdomen.  As  a  rule,  they  are 
easily  recognised,  as  they  are  dull  on  percussion,  doughy 
to  the  feel,  and  readily  receive  the  imprint  of  the  finger- 
tip. Repeated  copious  enemata  quickly  settle  the  nature 
of  the  tumour.  The  belly  has  been  opened  for  the 
removal  of  such  a  mass  under  the  belief  that  it  was  an 
ovarian  tumour. 

Obesity. — It  would  seem  unnecessary  to  mention  that 
undue  fatness  could  be  mistaken  for  an  ovarian  tumour, 
but  it  is  a  fact  that  such  errors  in  diagnosis  have  been 
committed,  apart  from  Lizar's  *  celebrated  case,  in  which, 
after  opening  a  woman's  belly  to  remove  a  supposed 
ovarian  tumour,  he  writes : — ^"  I  now  proceeded  to 
examine  the  state  of  the  tumour,  when,  to  my  astonish- 
ment, I  could  find  none."  In  continuing  the  description 
of  the  case,  he  explains  : — "  The  reason  why  all  of  us 
were  deceived  in  this  woman's  case  was  the  great  obesity 
and  distended  fulness  of  the  intestines,  together  with 
some  protrusion  pubic  of  the  spine  at  the  lumbar 
vertebrce." 

Abnormal  conditions  of  the  stomach  rarely  complicate 
the  diagnosis  of  ovarian   disease,  directly  or  indirectly,^ 
Such  cases,  however,  are  not  unknown. 

Dr.  Galabint  has  recorded  an  experience  illustrating 
this.  "  A  patient  had  been  sent  into  Guy's  Hospital, 
under  one  of  his  surgical  colleagues,  with  a  history  that 
she  had  been  tapped  for  ovarian  tumour,  and  the  fluid 
had  re-collected.  On  examination,  there  was  evidently  a 
large  space  containing  fluid  and  gas,  and  giving  a  succus- 
sion  splash.     Dr.  Galabin  was  not  disposed  to  think  that 

*  Ed.  Med.  and  Surg.  Journal,  vol.  xxii.  p.  253  ;  1824. 
t   Trans.  Obstet.  Soc. ,  London,  vol.  xxix.  p.  150. 


Se/^ocs  Perimetritis.  201 

the  fluid  was  contained  in  a  cyst.  At  an  exploratory 
operation,  however,  it  was  thought  that  there  was  an  irre- 
movable ovarian  cyst,  and  the  supposed  cyst  wall  was 
stitched  to  the  abdominal  wound.  Not  long  after,  food 
began  to  escape  through  the  wound  soon  after  it  was 
taken.  The  patient  died,  and  at  the  autopsy  it  was 
found  that  a  pseudo-cyst  had  been  formed  by  peritoneal 
adhesions,  and  that  there  was  a  fistulous  opening  into  it 
from  the  stomach." 

Serous  perimetritis,  described  by  Dr.  John 
Williams,*  is  probably  a  variety  of  hydroperitoneum, 
secondary  to  tubal  disease.  Serous  perimetritis  consists 
of  a  collection  of  inflammatory  exudation  in  the  recto- 
vaginal pouch,  covered  in  by  adherent  intestines,  which 
thus  gives  rise  to  the  signs  of  a  cyst  behind  the  uterus. 

The  following  abstract  of  a  case  recorded  by  Dr.  John 
Williams  will  serve  as  a  type  : — A  widow,  thirty  years  of 
age,  was  admitted  into  University  College  Hospital  with 
the  following  history :  A  month  previously  she  had  a 
rigor,  accompanied  with  great  pain.  Two  days  later 
menstruation  set  in,  accompanied  by  more  than  usual 
pain.  From  that  time  she  suffered  from  constipation  and 
painful  defecation.  Two  days  before  coming  to  hospital 
she  felt  a  sudden  pain  in  the  abdomen,  became  giddy, 
and  fainted.  On  admission  into  the  hospital,  examina- 
tion caused  so  much  pain  that  she  was  eventually 
examined  under  chloroform.  A  swelling  was  detected 
behind  the  uterus  ;  it  was  a  smooth  resisting  mass  of 
great  size,  which  might  have  been  a  tumour,  or  an 
enlarged  retroverted  uterus,  or  a  hgematocele.  The 
swelling  caused  protrusion  of  the  posterior  wall  of  the 
vagina. 

An  aspirating  needle  was  inserted  into  the  vaginal 

*  Trans.  Ohstet.  Soc,  London,  vo).  xxvii.  p.  169. 


2  02  Diseases  of  the  Ovaries. 

protrusion,  and  three  ounces  of  straw-coloured  fluid 
were  withdrawn.  The  needle  was  inserted  into  the 
retro-uterine  swelling,  and  a  small  quantity  of  similar 
fluid  was  obtained. 

Diarrhoea  set  in  a  few  days  later^  accompanied  by 
abdominal  distension,  tenderness,  thirst,  and  rigors. 
Death  occurred  sixteen  days  after  admission. 

At  the  post  mortem  examination  a  collection  of  coagu- 
lated peritoneal  fluid  was  found  behind  the  uterus,  and 
this  f^uid  was  closed  in  above  by  omentum  and  small 
intestines,  which  were  adherent  to  each  other  and  the 
fundus  of  the  uterus.  The  peritoneum  lining  the  cavity 
was  at  its  thinnest  part  at  least  an  eighth  of  an  inch  in 
thickness.  Unfortunately,  there  is  no  mention  of  the 
condition  of  the  Fallopian  tubes. 

With  our  present  knowledge  of  serous  perimetritis  it 
seems  that  irritant  material  causes  pelvic  peritonitis  :  the 
irritant  matter  is  probably  conveyed  to  the  peritoneum 
by  the  tubes  in  most  instances ;  the  inflammation  causes 
the  uterus,  tubes,  and  intestines  to  adhere,  and  thus 
isolate  the  recto-vaginal  pouch  of  the  peritoneum  from 
the  general  peritoneal  cavity.  The  inflammation  being 
of  mild  type,  serum  is  effused,  but  the  admission  of 
intestinal  gases  or  air  will  lead  to  suppuration, 

Doran*  has  recorded  the  details  of  a  case  of  anterior 
sei^oiis  perimetritis  simulating  ovarian  sarcoma  :  the  simu- 
lation was  so  strong  that  the  supposed  tumour  was 
explored  by  abdominal  section.  No  satisfactory  con- 
clusion was  arrived  at  during  the  operation.  In  the 
course  of  convalescence  the  swelling  almost  disappeared, 
and  Doran  came  to  the  conclusion  that  it  was  a  case 
of  serous  perimetritis.  Three  years  after  the  operation 
the  girl  died  of  tubercular  peritonitis. 

■^   Tra?is.  Ohsiet.  Soc,  London,  vol.  xxxi.  p.  217  ;  vol.  xxxiii.  p.  185 


203 


CHAPTER   XVII. 

THE    DIFFERENTIAL    DIAGNOSIS    OF    OVARIAN    TUMOURS 

{concluded). 

MORBID    CONDITIONS    OF    THE    BROAD    LIGAMENT. 

Many  morbid  conditions  of  the  bivad  ligament  simulate 
ovarian  tumours,  and  in  some  the  simulation  is  so  com- 
plete that  accurate  diagnosis  is  impossible.  The  following 
conditions  will  be  discussed  in  this  chapter : — 

Myo7tiata  of  the  broad  ligament  and  round  ligament  of 
the  uterus.  Tumours  of  the  ovarian  ligament.  Allantoic 
cysts.     Pelvic  cellulitis  and  its  varieties. 

Hydatid  cysts  of  this  region  were  discussed  in  the 
preceding  chapter,  and  broad  ligai?ient  pregnancy  is  so 
important  that  it  will  be  dealt  with  separately. 

Myomatous  twiiiotirs  may  arise  in  the  broad 
ligament,  and  cause  great  difficulty  in  diagnosis.  Un- 
striped  muscle  tissue,  apart  from  the  uterus,  exists  in 
three  situations  between  the  layers  of  the  broad  liga- 
ment : — I.  In  the  round  ligament  of  the  uterus  ;  2.  In 
the  ovarian  ligament ;  3.  In  the  connective  tissue  be- 
tween the  folds  of  the  ligament. 

Tumours  of  the  round  ligament  may  spring  from  it  in 
two  situations — (i)  Within  the  pelvis,  between  the  uterus 
and  internal  abdominal  ring  ;  (2)  In  the  inguinal  canal. 

Sanger*  has  recorded  an  example  of  the  first  variety 
in  a  paper  entitled  Welter e  Beitrdge  zur-  Lehre  von  den 
primdren  desmoid  en   Geschwillsten  der  Gebdr?nutterbdnder 

*  Arch.fur  Gyndkologie,  Bd.  xxi.  p.  279;  1883. 


2  04  Diseases  of  the  Ovaries. 

bcsondei's  der  llgamenta  rotunda,  and  has  collected  a  fair 
number  of  cases.  The  specimen  which  formed  the  basis 
of  his  paper  occurred  in  a  woman  twenty-two  years  of  age. 
She  had  had  three  children.  The  tumour  had  been 
noticed  many  years.  It  began  as  a  swelling  the  size  of  a 
dove's  egg  in  the  right  inguinal  canal.  When  she  came 
under  observation  the  tumour  was  of  large  size,  occu- 
pying the  right  side  of  the  pelvis,  and  extending  upwards 
towards  the  umbilicus.  It  was  removed,  but  the  patient 
died  twenty-four  hours  after  the  operation. 

It  presented  microscopical  characters  of  a  fibro-myo- 
sarcoma  of  the  right  round  ligament. 

Matthews  Duncan*  has  recorded  a  case  of  tumour  of 
the  round  ligament.  It  was  about  the  size  and  shape  of 
a  hen's  egg.  It  lay  quite  free  in  front  of  the  right  broad 
ligament.  The  right  round  ligament  could  be  traced  to 
its  surface,  where  it  ended  in  a  capsule.  Its  pedicle  was 
small  and  thick,  about  a  quarter  of  an  inch  broad.  The 
structure  of  the  tumour  was  that  of  a  dense  fibroid,  with 
numerous  cretaceous  points  near  its  centre,  and  having  a 
fibrous  capsule  from  the  round  ligament.  Dr.  Duncan 
thought  that  such  a  tumour  was  interesting,  as  it  might 
be  mistaken  for  an  ovary  if  felt  during  life. 

Tumours  of  the  round  ligament  lodged  in  the  inguinal 
canal  have  been  recorded  by  Sir  Spencer  Wells,  f  He 
removed  two,  both  from  the  right  side,  in  w^omen  aged 
forty  and  fifty  years  respectively.  One  was  the  size  and 
shape  of  a  cocoa-nut,  and  the  other  was  as  large  as  an 
orange.  In  each  case  .the  tumour  occupied  the  inguinal 
canal,  and  was  removed  without  difficulty. 

"  Histologically,  the  growth  in  each  case  was  simply 
an  excess  of  the  fibrous  tissue  of  the  round  ligament  of 
the  uterus." 

*   Trans.  Obstet.  Soc,  Edin.,  1876,  vol.  iv.  p.  195. 
f  Trans.  Path.  Soc,  vol.  xvii.  p.  188. 


Myoma  of  the  Broad  Ligament.  205 

Tumours  absolutely  unconnected  with  the  ovary,  ova- 
rian ligament,  uterus,  or  round  ligament,  occasionally 
arise  from  the  muscle  tissue  and  connective  tissue  which 
lie  between  the  folds  of  the  broad  ligament.  Such  tu- 
mours have  been  little  studied. 

My  first  experience  of  this  variety  of  myoma  was  a 
specimen  which  Dr.  Bantock  removed  by  abdominal 
section  from  a  married  woman  thirty-nine  years  of  age. 
She  was  the  mother  of  four  children.  The  operation  was 
one  of  great  difiiculty.  The  tujiiour  dipped  between  the 
layers  of  the  broad  ligament,  and  the  reflection  of  the 
peritoneum  from  the  tumour  to  the  parietes  was  above 
the  level  of  the  crest  of  the  ilium.  The  woman  made  a 
satisfactory  recovery.  The  specimen  was  exhibited  at 
the  British  GyuEecological  Society,  November,  1887,  and 
subsequently  placed  in  my  hands  for  examination.  I 
made  the  subjoined  report : — * 

"The  specimen  consists  of  a  uterus  and  its  appen- 
dages, associated  with  two  large  tumours.  When  first 
removed,  the  parts  weighed  11 J  lbs. 

"  On  reference  to  the  drawing  which  accompanies  the 
report,  it  will  be  seen  that  the  uterus  is  of  normal  size 
and  shape ;  the  Fallopian  tubes,  ovaries,  and  round 
ligaments  are  spread  out  and  stretched  by  the  tumours. 
These  parts  are  normal,  except  that  near  the  fimbriated 
end  of  the  right  tube  there  were  a  few  small  cysts. 

"  Lying  between  the  folds  of  the  right  broad  ligamicnt 
we  find  an  oval-shaped  tumour,  measuring  nine  inches  in 
its  long,  and  five  inches  in  its  short,  axis.  At  one  spot 
this  tumour  approached,  and  was  attached  to,  the  right 
side  of  the  fundus  uteri.  A  portion  of  this  was  broken 
off  with  the  ovary  when  it  came  into  my  possession. 

"  The  left  broad  ligament  is  occupied  by  a  similar  but 

*  Jouni,  Brit.  Gyn.  Soc,  vol.  iii.  p.  493. 


2o6  Diseases  of  the  Ovaries. 

much  larger  tumour,  measuring  eight  inches  across  the 
cut  surface  and  thirteen  inches  in  length.  A  nodule, 
projecting  from  the  tumour,  has  forced  its  way  between 
the  layers  of  the  mesosalpinx,  and  separated  the  ovary 
from  the  Fallopian  tube.  A  large  tuberous  portion  was 
adherent  to  the  lower  part  of  the  main  mass.  Ex- 
ternally the  tumours  were  covered  by  a  dense  fibrous 
capsule.  On  dividing  the  larger  tumour,  its  centre  was 
found  to  be  occupied  by  an  area  of  softening,  and  was  as 
succulent  as  an  orange.  The  hmits  of  this  degenerate 
portion  were  sharply  indicated  by  a  wall  of  calcified  tissue, 
in  some  places  a  quarter  of  an  inch  in  thickness.  Smaller 
tracts  of  softening  dotted  the  surface  of  the  section.  The 
periphery  of  the  tumour  was  firm,  and  in  some  places  as 
resistant  as  a  uterine  myoma.  The  tumour  in  the  right 
ligament  presented  a  few  tough  nodules.  Under  the 
microscope,  sections  from  the  periphery  of  the  tumour 
exhibited  the  familiar  arrangement  of  dense  fibroid  tissue, 
and-  in  some  places  a  whorled  disposition  of  the  fibres 
was  obvious.  The  softer  parts  of  the  mass  were  made 
up  of  spindle-cells,  whilst  the  succulent  parts  were  in  a 
condition  of  myxomatous  degeneration.  The  tumours 
must  be  regarded  as  spindle-cell  sarcomata"  (Fig.  6i). 

At  the  time  of  examining  this  specimen  the  only 
tumour  known  to  me  with  which  to  compare  it  was  that 
which  Virchow  called  fibroma  molhiscum^  an  example  of 
which  has  been  described  by  Sir  Spencer  Wells.* 

One  specimen  removed  by  this  distinguished  surgeon 
weighed  68  lbs. 

Myomata  of  the  broad  ligament,  when  large,  carry 
the  anterior  layer  of  the  hgament  upwards  as  they  rise 
out  of  the  pelvis  into  the  belly ;  thus,  in  some  cases  the 
tumour  may  extend  upwards  to  the  umbilicus  external  to 
the  peritoneum. 

*  Ovarian  and  Uterine  Tumours,  p.  500  ;    1882. 


Fig.  6i.— Myoma  of  the  Broad  Ligaments.     {Brit.  Gyn.  Soc. 
f,  Fallopian  lubes  ;  o    ovaries;  u,  uterus;  c,  cysts. 


2o8 


Diseases  of  the  Ovaries. 


A  specimen  illustrating  this  was  exhibited  by  Dr. 
Aveling  to  the  Gynecological  Society,  London.*  The 
tumour  was  ten  inches  long,  seven  in  width,  and  weighed 
nearly  5  lbs.  It  had  a  thick  fibrous  capsule,  and  on 
section  resembled  a  sponge;  the  loculi  were  filled  with 
gelatinous  tissue.  Lodged  in  the  substance  of  the  tu- 
mour were   several   rounded    hard    nodules  as  large  as 


Fig.  62. — Broad  Ligament  Myoma.     {8?'it.  Gyu.  Soc.) 

N,   Nodule. 

walnuts,  resembling  small  uterine  myomata  on  section, 
and  exhibiting  the  same  whorled  disposition  of  fibres, 
and  agreeing  with  them  histologically  (Fig.  62). 

In  my  report  of  this  specimen  I  identified  this  tumour 
with  the  filn'ovia  moUuscuni  of  Virchow,  and  believed  it 
arose  in  the  urachus ;  but  since  that  date  I  have  had 
many  opportunities  of  more  carefully  investigating  such 
tumours,  and  now  believe  that  it,  like  the  large  specimen 
removed  by  Bantock,  was  a  myoma  of  the  broad  ligament, 

*  Jou7-nal  of  the  Di'it.  Gyu.  Soc,  vol.  ii.  p.  187. 


Allantoic  Cvsts.  209 

which  had  extended  upwards  in  the  sul^serous  tissue, 
between  the  peritoneum  and  the  anterior  abdominal 
wall. 

Broad  ligament  myomata  do  not  always  attain  such 
large  .proportions.  Specimens  have  come  under  my 
notice  which  in  shape  and  size  resembled  cocoa-nuts. 

Doran*  has  described  a  large  myoma  of  this  variety 
weighing  16  lbs.,  which  he  successfully  removed;  he 
believed  that  it  took  origin  from  the  ligament  of  the 
ovary. 

It  is  necessary  to  distinguish  between  a  myoma  of  the 
broad  ligament  and  a  myoma  growing  from  the  side  of 
the  uterus  and  separating  the  layers  of  the  broad 
ligament. 

Myomata  of  the  ovarian  ligamejit  are  very  exceptional, 
and  rarely  exceed  a  hen's  egg  in  size. 

Allantoic  or  iiraclius  cysts  occasionally  give  rise 
to  difficulty  in  diagnosis.  The  urachus  is  the  normally 
impervious  cord  passing  from  the  bladder  to  the  um- 
bilicus ;  like  the  bladder,  it  represents  a  persistent  portion 
of  the  allantois.  The  urachus  is  liable  to  several  in- 
teresting abnormalities.  Instead  of  dwindling  to  an 
impervious  cord,  it  may  dilate  and  form  a  cyst  as  large  as 
the  bladder.  Sometimes  the  cyst  communicates  with 
the  bladder,  the  epithelium  of  the  two  cavities  being 
directly  continuous. 

Lawson  Taitf  has  recorded  cases  of  allantoic  cysts  of 
large  size.  Of  course  such  cysts,  like  over-distended 
bladders,  are  situated  between  the  peritoneum  and  the 
anterior  abdominal  wall. 

Rows  of  small  cysts  are  sometimes  seen  in  the 
urachus  whilst  the  tissues  are  being  divided  in  abdominal 

*  British  Med.  Journal,  1889,  vol.  i.  p.  1287. 

f  Journal  of  the  Brit.  Gyn.  Sac,  vol.  ii.   p.    328  :     '•  On   Twelve 
Cases  of  Extra-Peritoneal  Cysts." 

O 


2IO  Diseases  of  the  Ovaries, 

incisions,  but  as  they  are  rarely  larger  than  ripe  currants, 
they  scarcely  call  for  comment. 

Pelvic  cellulitis,  or  inflammation  of  the  connective 
tissue  of  the  broad  ligament,  cannot  be  discussed  in  a 
work  of  this  character,  except  so  far  as  it  is  concerned 
in  the  differential  diagnosis  of  pelvic  swellings. 

A  few  years  ago  it  was  customary  to  apply  the  term 
pelvic  cellulitis  to  any  hard  irregular  mass  which  could 
be  detected  on  one  or  l)oth  sides  of  the  uterus.  With 
our  present  knowledge  it  is  clear  that  many  conditions 
were  formerly  erroneously  included  under  this  term,  and 
the  attempt  to  divide  pelvic  cellulitis  into  two  varieties — - 
such  d.^  parametritis  when  the  inflammation  is  confined 
to  the  connective  tissue,  din^  perimetritis  when  it  aftects 
the  pelvic  peritoneum — was  a  sound  step  in  the  direction 
of  discriminating  between  the  various  kinds  of  pelvic 
inflammation. 

Pelvic  cellulitis  signifies  inflammation  of  the  con- 
nective tissue  enclosed  between  the  folds  of  the  broad 
ligament;  pathologicafly  it  does  not  differ  from  septic 
inflammation  of  cellular  tissue  in  more  superficial  regions 
of  the  body.  It  is  usually  associated  with  septic  changes 
originating  in  the  cervix  and  body  of  the  uterus, 
associated  with  abortion,  delivery  at  term — especially  in- 
strumental delivery — and  operations  upon  the  uterus. 

The  changes  consist  in  the  infiltration  of  the  con- 
nective tissue  of  the  broad  ligament  with  inflammatory 
products,  which,  like  such  products  in  general,  may 
undergo  resolution,  or  suppurate  and  give  rise  to  a  pelvic 
abscess. 

To  recognise  clinically  pelvic  cellulitis  it  is  necessary 
to  remember  that  in  nearly  all  cases  there  is  a  history 
of  abortion,  delivery,  or  operative  interference  with  the 
uterus. 

On   physical    examination  in    the    early   stage  the 


Pelvic  Cellulitis.  211 

infiltration  will  be  found  to  surround  the  neck  of  the 
uterus  like  a  ring,  and  then  extend  indefinitely  into  each 
broad  ligament.  The  mobility  of  the  uterus  is  impaired, 
and  it  seems  as  if  this  organ  were  embedded  in  some 
firm  material.  Should  the  inflammation  continue,  the  in- 
filtration will  extend  backwards  and  surround  the  rectum ; 
anteriorly  it  will  pass  forwards  under  the  anterior  fold  of 
the  broad  ligament,  and  creep  up  the  anterior  abdominal 
wall,  even  as  high  as  the  umbilicus. 

Occasionally  it  infiltrates  the  connective  tissue  in  the 
cave  of  Retzius,  and  forms  sometimes  a  rounded  swelling 
immediately  above  the  pubes ;  in  a  small  proportion  of 
cases  the  exudation  extends  into  the  tissue  between  the 
cervix  uteri  and  bladder,  raises  up  the  peritoneum,  and 
obliterates  the  utero-vesical  pouch.  Such  exudations 
sometimes  give  rise  to  considerable  hypogastric  swellings, 
and  cause  extreme  irritability  of  the  bladder. 

In  a  very  large  proportion  of  cases  of  pelvic  cellulitis 
the  swelling  subsides,  and  the  patient  recovers ;  the  re- 
mainder suppurate,  the  pus  escaping  by  fistulous  tracks 
through  the  rectum,  vagina,  bladder,  or  through  the 
anterior  abdominal  walls  immediately  above  Poupart's 
ligament,  or  near  the  umbilicus. 

The  common  forms  of  pelvic  cellulitis  are  rarely  mis- 
taken for  other  conditions,  and  should  there  be  any 
doubt,  a  little  patience  will,  in  most  cases,  enable  a  correct 
diagnosis  to  be  made,  for  rest  will  promote  absorption  of 
the  exudation.  In  cases  where  suppuration  ensues,  the 
clinical  signs  incidental  to  that  process  will  declare  the 
presence  of  pus,  and  indicate  the  line  of  treatment. 

The  unusual  variety  which  affects  mainly  the  con- 
nective tissue  between  the  uterus  and  bladder  may  give 
rise  to  difficulty.  An  instructive  specimen  illustrating 
this  has  been    described    by   Dr.   Griffith.*     The   parts 

*   Trans.  Obstet.  Soc,  London.,  vol.  xxix.  p.  149. 
O    2 


212 


Diseases  of  the  Ovaries. 


which  are  represented    in  Fig.   63  show  a  large  cavity, 
which  contained    pus  between    the  uterus  and  bladder, 


a 


^   - 


l-d 


Fig,  63. — Sagittal    Section    of   the    parts    involved    in  the  so-called  Anterior 

Perimetritis.     (After  Griffith.) 

a,  y,  Abscess  cavity  ;    l>,  bladder ;  d,  uterus  ;  c,  ovary  ;  £-,  ureter  ;   e,  extension  of  abscess 

between  vagina  and  bladder  ;  X,  fimbriated  end  of  right  tube. 


and  was  roofed  by  that  portion  of  the  peritoneum  which 
lines  the  utero- vesical  pouch. 

The  chief  physical  signs  of  this  condition  are  hypo- 
gastric tumourj  which  can  also  be  felt  through  the 
anterior  vaginal  wall,  and  vesical  imtability.     The  tumour 


Fericmcal  Abscess.  213 

simulates  a  distended  bladder,  and  may  be  mistaken  for 
an  inflamed  and  suppurating  ovarian  cyst. 

In  the  drawing  a  point  of  some  interest  is  omitted. 
An  examination  of  the  parts  preserved  in  the  museum 
of  the  Royal  College  of  Surgeons  shows  that  the  obliterated 
hypogastric  arteries  and  the  ■ii7'achiis  traverse  the  anterior 
part  of  the  cavity;  this  is  sufficient  to  prove  that  the 
cavity  is  extra-peritoneal,  and  that  the  term  anterior  para- 
metritis would  be  more  appropriate.  Whether  it  be 
termed  peri-  or  para-metritis  it  would  have  perplexed  a 
surgeon  had  the  abdomen  been  opened  for  its  relief 

Pericsecal  abscess.  —  Inflammatory  affections 
about  the  c^cum  are  occasionally  confounded  with  sup- 
purating ovarian  cysts  and  pelvic  abscesses.  It  is  generally 
believed  that  inflammation  of  the  vermiform  appendix  is 
rare  in  females.  The  truth  is  that  appendicitis  occurs  in 
women  but  is  usually  regarded  as  pelvic  cellulitis.  It 
should  be  remembered  that  the  pus  in  a  retro-peritoneal 
abscess,  secondary  to  appendicitis,  readily  finds  its  w^ay 
between  the  layers  of  the  right  broad  ligament,  the 
disposition  of  the  peritoneum  favouring  the  burrowing 
of  pus  in  this  direction. 


214 


CHAPTER  XVIII. 

TREATMENT    OF    OVARIAN    TUMOURS. 

The  treatment  of  an  ovarian  tumour,  including  in  this 
general  term  tumours  of  the  oophoron,  paroophoron  and 
parovarium,  is  early  removal.  It  has  been  shown  by  an 
overwhelming  amount  of  evidence  that  the  earlier  these 
tumours  are  removed — that  is,  before  they  have  acquired 
compKcated  adhesions  to  important  organs,  or  produced 
any  dangerous  pressure  effects  upon  the  kidneys— the 
more  likely  is  the  operation  to  be  followed  by  success. 
Recent  writers  on  ovarian  disease  have  insisted  upon  the 
fact  that  the  pernicious  practice  of  tapping,  formerly  so 
much  advocated,  but  now,  fortunately,  almost  banished, 
renders  subsequent  operations  for  the  removal  of  the 
cyst  much  more  difficult,  and  therefore  more  dangerous 
to  life. 

I'araceiitesis,  or  tapping*,  is  now  but  rarely 
resorted  to  for  ovarian  cysts.  Ovariotomy  is  such  a 
successful  operation  that  it  involves  little  risk  and  is 
curative.,  whilst  tapping  \^  palliative.,  and  often  harmful. 

Tappifig  is  attended  with  several  risks.  If  air  be 
admitted  into  the  cyst  during  the  procedure,  or  the 
instrument  be  septic  from  want  of  care  and  cleanliness 
on  the  part  of  the  operator,  i^iflanunation  and  suppuration 
of  the  cyst  result,  with  all  the  attendant  dangers. 

The  fluid  may,  in  spite  of  care  and  caution,  leak  into 
the  peritoneal  cavity,  and  should  it  possess  irritating 
qualities,  idXdX  perito7iitis  will  be  the  consequence. 

Should  the  cyst  conidin papillojfiata,  as  is  so  frequently 
the  case  with  paroophoritic  cysts,  epithelial  elements  may 
be  disseminated  broadcast  over  the  peritoneum.     Should 


Treatment  of  Suppurating  Cysts.         215 

these  possess  malignant  characters,  the  significance  of  the 
accident  is  very  obvious. 

Should  there  be  an  error  of  diagnosis,  and  a  large 
uterine  myoma  be  stabbed  with  the  trocar,  the  patient  will 
be  placed  in  great  danger  from  hamiorrhage. 

In  some  varieties  of  cysts  the  fluid  will  not  run 
through  the  cannula,  and  in  multilocular  cysts  it  would 
be  impossible  to  empty  all  the  loculi. 

Very  exceptionally  it  may  be  requisite  to  tap  an 
ovarian  cyst  where  a  patient  is  not  in  a  condition  to 
bear  ovariotomy.  A  few  writers  recommend  it  when  a 
patient  is  suffering  from  some  intercurrent  trouble,  such 
as  bronchitis,  or  where  the  pressure  of  the  tumour  causes 
anasarca  of  the  lower  limbs. 

Under  the  latter  condition  it  would  seem  more  in 
accordance  with  general  surgical  principles  to  at  once 
perform  ovariotomy,  especially  when  there  is  no  reason 
to  fear  malignancy.  I  have  performed  ovariotomy  under 
such  conditions  with  the  happiest  results. 

When  it  is  judged  really  necessary  to  tap,  instead  of 
performing  ovariotomy,  the  safest  instrument  to  use  is 
the  aspirator. 

Some  of  the  records  of  cases  in  which  patients  have 
been  tapped  read  almost  like  fables.  Any  surgeon  con- 
templating the  treatment  of  an  ovarian  or  parovarian 
cyst  by  this  method  would  do  well  to  read  the  brief 
details  of  the  case  furnished  on  page  151  of  this  book. 

There  are  very  few  contra-indications  to  ovariotomy ; 
this  operation  is  now  performed  under  what  would  have 
formerly  been  regarded  as  prohibitive  conditions.  Some 
of  these  we  will  consider. 

Inflamed  and  suppnratiug^  cysts. — The  treat- 
ment of  a  suppurating  ova?-ia?i  cyst  depends  upon  its 
situation.  In  acute  suppuration  of  large  cysts  imme- 
diate removal  of  the  tumour  is  the  proper  practice,  and 


2i6  Diseases  of  the  Ovaries. 

this  was  forced  upon  the  profession  by  Dr.  Keith.* 
Writing  in  1875,  he  expresses  himself  thus: — 

"  Ten  years  ago,  when  cases  of  ovariotomy  were  few, 
and  there  was  Httle  to  guide  one  in  unusual  circum- 
stances, a  young  woman  in  the  last  stage  of  ovarian 
disease  came  to  me  a  long  journey  from  the  north.  The 
fatigue  of  travelling  was  too  much  for  the  strength  that 
was  left,  and  she  arrived  completely  worn  out.  It  did 
not  seem  possible  that  in  such  a  condition  life  could  be 
prolonged  many  days,  for  the  pulse  was  almost  imper- 
ceptible :  there  were  vomiting  and  diarrhoea,  oedematous 
limbs,  and  albuminous  urine,  whilst  a  profuse  foetid 
discharge  was  going  on  from  an  opening  near  the  um- 
bilicus. The  intensity  of  this  putridity  was  such  that 
one  became  aware  of  it  before  entering  the  house,  and 
the  antiseptics  of  those  days  were  powerless  to  arrest  it. 
Day  after  day  I  went,  expecting  and  hoping  to  find  her 
dead  ;  yet,  though  shrivelled  up  like  a  mummy,  with  an 
aspect  scarcely  human,  respiration  went  on  for  nearly  a 
month,  the  brain  retaining  its  clearness,  acutely  alive  to 
what  was  going  on.  To  remove  a  putrid  cyst  in  such  a 
condition  of  feebleness  did  not  occur  to  me." 

In  December,  1864,  a  patient  with  a  large  tumour 
came  under  his  care.  She  had  been  jolted  for  some 
hours  in  a  coach,  and  in  the  hope  of  relieving  the  pain 
thus  set  up,  tapping  was  performed.  The  pain  was  not 
relieved  ;  flatulent  abdominal  distension  became  excessive, 
and  typhoid  symptoms  set  in.  Ovariotomy  was  per- 
formed during  the  semi-delirium  of  septic  fever.  The 
peritoneum  was  acutely  inflamed  and  intensely  livid. 
Recent  lymph  was  everywhere  present,  and  the  cyst 
putrid.  The  operation  lasted  two  hours.  V/hen  the 
patient  was  placed  in  the  bed  she  was  cold,  vomiting, 
and  nearly  pulseless.       She  regained  heat  rapidly,  the 

*  Edi?iburgh  J\Ied.  and  Siirg.  Jonnial,  1875,  p.  673. 


Treatment  of  Suppurating  Cysts.         217 

delirium    disappeared ;    there   were    warm    perspiration, 
much  sleep,  and  recovery  without  a  drawback. 

This  was  in  1864.  Writing  in  1875,  Keith  was  able 
to  give  details  of  ten  cases  in  which  he  had  operated 
upon  suppurating  cysts,  with  only  one  death.  His  bold- 
ness and  enterprise  were  soon  imitated  by  other  sur- 
geons, and  the  practice  became  estabhshed  that  suppura- 
ting ovarian  cysts  should  be  immediately  removed. 

The  treatment  of  ovarian  dermoids,  when  they  have 
suppurated  and  opened  into  mucous  canals,  is  not  always 
so  precise.  In  the  majority  of  cases  an  attempt  should 
be  made  to  extirpate  the  tumour,  and  this  method  has 
been  successful  in  a  large  number  of  instances,  and  the 
operation  is  not  always  difficult.  In  many  cases  the 
tumour  is  so  bound  down  that  its  removal  is  imprac- 
ticable. When  such  cysts  have  opened  into  the  bladder 
or  vagina,  their  contents  may  sometimes  be  successfully 
evacuated  through  the  fistulous  opening  after  dilatation  of 
the  vagina  or  urethra,  as  the  case  requires. 

Pregnancy  is  no  bar  to  ovariotomy  ;  indeed,  experience 
teaches  that  when  an  ovarian  tumour  complicates  preg- 
nancy the  tumour  should  be  removed,  because  the 
patient  runs  a  great  risk  of  axial  rotation  of  the  tumour, 
not  only  during  pregnancy,  but  especially  at  the  time  of 
delivery,  or  in  the  event  of  miscarriage.  Other  serious 
risks  are  rupture  of  the  cyst,  and  even  rupture  of  the  uterus. 

Dr.  Ogier  Ward*  recorded  a  case  in  which  a  cyst  of 
the  right  ovary,  as  large  as  a  cocoa-nut,  so  impeded 
labour,  by  preventing  the  head  of  the  fcetus  entering  the 
true  pelvis,  that  the  uterus  ruptured  and  the  patient  died. 

Rupture  of  the  vagina  has  been  reported  during  labour, 
and  the  ovarian  cyst  has  protruded  through  the  rent.f 

*  Trans.  Path.  Soc,  vol.  v.  p.  219. 

t  Kersmill,  Brit.  Med.  Journal,  1880,  vol.  ii.  p.  16.  See  also 
Barnes,  Diseases  of  Women,  p.  346. 


2l8 


Diseases  of  the  0^'aries. 


It  is  undeniable  that  in  some  instances  women  with 
an  ovarian  tumour  have  been  known  to  pass  through 
several  pregnancies  without  mishap.  Nevertheless,  the 
danger  to  life  under  such  conditions  is  far  greater  than 
the  risks  of  ovariotomy. 

A  large  number  of  instances  of  successful  ovariotomy 
during  pregnancy  has  been  recorded,  from  which  it  may 
be  safely  concluded  that  the  operation  should  be  under- 
taken, if  possible,  before  the  fourth  month  of  gestation, 
in  order  to  avoid  abortion. 

In  several  instances  double  ovariotomy  has  been  per- 
formed successfully  during  pregnancy.  A  few  recorded 
cases  are  given  in  the  accompanying  table  : — 

Double  Ovariotomy  during  Pregnancy. 


OPERATOR. 

Stage  of 
Pregnancy. 

Nature  of 
Tumours. 

Result. 

Place  of  Record. 

Thornton . . . 

Fourth 

Dermoids  ... 

Recovered  :        preg- 

Trans.  Obstet.    So- 

month. 

nancy  went  to   8th 
month. 

ciety,  London,  vol. 
xxviii.  p.  41. 

Mund6     ... 

Fifth  month. 

Dermoids  ... 

Miscarried   72    hours 
after       operation  : 
recovered. 

Am.  Journal  0/ Ob- 
stet., vol.  XX.  p. 
730- 

Potter 

About  fourth 

Not  stated... 

Recovered :  delivered 

A  711.  Jourfial  oj"  Ob- 

month. 

of  a  child  s  months 
after  operation. 

stet.,    vol.  xxi.  p. 
1028. 

Montgom- 

Third month 

Removed 

Recovered  :       preg- 

A m.  Journal  0/  Ob- 

ery. 

both  ovar- 

nancy     went       to 

stet.,     vol.      xxi. 

ies. 

term. 

p.  10S4. 

Bantock   ... 

Third  month 

Dermoids  ... 

Recovered  :        preg- 
nancy   went    to    8 
months. 

Jo2C7-nal  o/the  Gyn, 
Soc.  0/  Gt.  Brit., 
vol.  vi.  p.  4. 

Meredith... 

Third  month 

Papilloma- 

Recovered :    went  to 

Trans.   Obstet.    So- 

tous cysts. 

term. 

ciety,  London,\Q\. 
xxxii.  p.  374. 

Meredith... 

Third  month 

Dermoid  and 
a    multilo- 
cular  cyst. 

Recovered  :   went  to 
term. 

Unpublished. 

Bateman*  has  recorded  a  case  in  which  Sir  Spencer 
Wells  successfully  operated  during  the  fourth  month  of 
pregnancy  for  an  ovarian  cyst  which  had  ruptured. 

The  admirable  results  which  follow  even  double 
ovariotomy  during  pregnancy  form  a  striking  contrast  to 


*  Lancet,  1869,  vol.  ii.  p.  400. 


Ol''ARI07VMV  AND    PrEGNANCV. 


219 


the  risks  such  patients  run  when  it  bee  ^mes  necessary  to 
perform  the  operatioi  during  the  puerperal  period. 

These  are  shown  in  an  instructive  manner  by  the 
following  case  reported  by  Sippel : — 

A  woman  with  an  ovarian  tumour  became  pregnant ; 
at  the  seventh  month  she  was  attacked  with  severe  pain 
in  the  abdonien,  accompanied  with  distension  and  high 
temperature  (101-5'').  The  tenderness,  at  first  confined 
to  the  region  of  the  tumour,  became  general.  This  fact, 
and  the  sudden  accession  of  pain  and  fever,  suggested 
torsion  of  the  pedicle,  and  an  operation  was  advised. 
She  was  admitted  into  the  hospital  for  that  purpose,  but 
the  same  night  she  was  delivered  of  a  living  child.  It 
was  decided  to  postpone  operative  interference,  so  as  to 
allow  involution  of  the  uterus.  The  symptoms  con- 
tinued so  urgent  that,  in  order  to  avoid  a  fatal  issue,  the 
abdomen  was  opened  :  the  incision  extended  above  the 
umbilicus,  on  account  of  the  size  of  the  tumour.  The 
pedicle  was  found  twisted  once  on  its  axis,  and  the 
circulation  arrested.     The  patient  made  a  good  recovery. 

The  appended  table  contains  references  to  a  few 
similar  cases  : — 


Ovariotomy  soon  after  Delivery  at  Term. 


Date  after 

Reason  for 

Ophrator. 

Delivery. 

Interference. 

Result. 

Place  of  Record. 

Gooding  ... 

5  weeks  after  Suppurating 

Death    after     39 

Lancet,     1873,     vol 

cyst. 

^days 

ii.  p.  493. 

Veit 

4  days 

Torsion 

Death       in       12 
hours  ... 

Zeitschri/t  fllr  Ge- 
burtsh.  7mdGyndk. , 
Bd.  ix.  s.  22Q, 
1883. 

*  John  Wil- 

During     la- 

Recovery 

Trans.    Obstet.    So- 

liams. 

bour. 

ciety,  London,  vol. 
XX vi.  p.  203. 

John     Wil- 

31 days  after  Suppuration    of 

Recovery 

Brit.  Med.  Journal, 

liams. 

abortion  at 

cyst,         after 

vol.     ii.     p.      973, 

the       fifth 

tapping. 

1880. 

month. 

Sippel 

Second  week ' Torsion 

Recovery 

Centralblatt  j'tlr 
Gyn.,  Ap.  7,  188S. 

*Dr. -^ 

(Villiams  had 

removed  the  left 

ovary  for  cystic 

disease  in  1870. 

220 


Diseases  of  the  Ovaries. 


These  facts  shovv  that  neither  pregnancy  nor  recent 
delivery  offers  serious  impediment  to  the  performance 
of  ovariotomy. 

The  accompanying  table  shows  that  even  in  very  ad- 
vanced life  the  operation  has  been  performed  with  a  very 
encouraging  measure  of  success. 


Ovariotomy  performed  on  Patients  over  Seventy  Years 

OF  Age. 


Operator. 

Age  of 
Patient. 

Result. 

PLACE  OF  Record. 

Janvrin     

77       ••• 

Success       

Atn.  Journal  of  Obstet., 
-xvii.,  1884,  p.  171. 

Bennett  of  Connec- 

75      ■•• 

Success      

Brit.  Med.  Journal,    1861, 

ticut 

vol.  ii.  p.  532. 

Schroeder  ... 

79       ... 

Success      ...        \ 

Olshausen,  Krankheiten  der 

Schroeder 

8o       ... 

Success      ...        j 

Ovarit-n,  s.  394. 

Wilcke  of  Halle... 

77 

Success      

Ditto. 

Fancourt     Barnes 

70       ... 

Success      

Provincial    Med.    JourJial 

1888. 

Sir  Spencer  Wells 

70       ... 

Success      

Medico-Chir.  Trans.,  vol. 
Ix.  pp.  224  and  227. 

Sir  Spencer  Wells 

77 

Death         

Thornton 

70       ... 

Success      

Medico-Chir.  Trans.,  vol. 
Lx.x.  pp.  57,  64,  and  75. 

Thornton  ... 

71 

Success 

Thornton  ... 

70 

Incomplete  opera- 
tion ;     death  in 

48  hours 

Bantock    ... 

71       ... 

Success      

Medico-Chir.  Trans.,  vol. 
Ixiv.  p.  128. 

Meredith 

70       ... 

Success      

Med.-Chir.  Trans.,  vol. 
Ixxii.  p.  50. 

Halliday  Croom... 

70       ... 

Recovery 

Obstet.  Trans.,  Edin.,  vol. 
xiv.  p.  94. 

Lawson  Tait 

70       ... 

Recovery  

Brit.  Med.  Joiirnal,  1886, 
vol.  i.  p.  923. 

Skene  Keith 

70       ... 

Recovery 

Brit.  Lied.  Journal,  1087 
vol.  i.  p.  271. 

Skene  Keith 

75       ••■ 

Incision  :      drain- 
age ;    recovery 

Ditto. 

Homans    ... 

82       ... 

Recovery  

Brit.  Med.  ^T'  S7trg.Journa 

May  3,  t888. 

Owens  of  Brisbane 

80       .., 

Recovery 

Journal  Brit.  Gyn.  Society 
vol.  iv.  p.  88. 

Keith  (Thomas)... 

73       - 

Recovery 

Brit.  Med.  Jour.,  l^^S  vol. 
ii.  p.  592. 

Davis         

75       ••• 

Recovery 

Jo7ir7i.  Brit.  Gyn.  Society, 
vol.  iii.  p.  413. 

Holland    

76       ... 

Recovery 

Journ.  Brit.  Gyn.  Soc,  part 

xxvi.  p.  179. 

The  case,  mentioned  in  a  few  works,  in  which  Dr 


Ovariotomy  and  Sarcoma.  221 

Miner  is  stated  to  have  operated  successfully  at  82, 
turns  out  to  be  a  misprint  for  32!*  W.  L.  Atlee's 
case,  so  frequently  stated  to  be  78,  should  be  68. 

Ovariotomy  in  young  children  is  very  successful.  -  Of 
the  sixty  cases  collected  in  the  tables,  thirty-five  non- 
sarcomatous  ovarian  tumours  were  submitted  to  ovari- 
otomy,  thirty-one  recovered  and  four  died,  a  mortality  of 
only  1 1 '4  per  cent. 

The  nature  of  the  tumour  influences  materially  the 
result.  A  glance  at  such  meagre  records  as  we  possess 
of  the  history  of  women  who  have  had  ovariotomy  per- 
formed for  ovarian  sarcoma  indicates  that  the  subject  is 
one  demanding  close  study.  Thornton  f  has  published 
records  of  ten  cases  submitted  to  operation.  Of  these, 
three  died  from  the  effects  of  the  operation.  Of  the 
seven  which  recovered,  one  remained  in  good  health 
and  had  a  child  two  years  later,  one  died  a  few  months 
after  the  operation  from  recurrence  in  the  pelvis,  another 
came  under  observation  with  recurrence  eighteen  months 
later ;  the  remaining  four  all  died  within  a  year  of  the 
operation  from  dissemination  of  the  growth. 

The  risks  of  ovariotomy  for  sai^coiuata  are  very  great. 
An  analysis  of  the  sixty  cases  tabulated  on  page  87 
shows  that  out  of  forty-six  ovariotomies  the  results 
were  : — 

Dermoids     ...     24  Deaths     ..     3         Mortality     12*5  per  cent. 

Sarcomata    ...     11  ,,         ...     8  ,,  72*7         ,, 

Cysts      II  ,,  ...      I  ,,  g-o  „ 

Jessop's  case  is  included  among  the  sarcomata. 
It  is  also  well  established  that  convalescence  is  very 
tardy  after  ovariotomy  for  sarcoma. 

It  is  impossible  to  state  with  anything  like  precision 

*  See  Doran  and  Billings,  Bost.  Med.  and  Surg.  Journal,  1888,  p. 
.638. 

f  Med.  Times  a?id  Gazette^,  April,  1883. 


222  Diseases  of  the  Ovaries. 

the  mortality  of  an  operation  like  ovariotomy.  It  has 
been  shown  over  and  over  again  that  when  the  operation 
is  undertaken  by  surgeons  who  have  devoted  attention  to 
this  class  of  surgery  the  risk  is  very  small ;  indeed, 
ovariotomy  generally  may  be  described  as  the  safest  of 
the  major  operations  of  surgery.  In  skilful  hands  an 
uncomplicated  ovariotomy  is  not  attended  with  more 
risks  than  amputation  of  a  mamma  without  removal  of 
the  axillary  glands. 

The  forms  of  ovarian  tumour  which  give  the  surgeon 
most  anxiety  are  those  with  firm  pelvic  adhesions ; 
paroophoi'itlc  cysts,  with  papillary  contents  which  burrow 
deeply  between  the  layers  of  the  broad  ligament ;  and 
■  lastly,  ovarian  sarcomata.  The  size  of  the  tumour  rarely 
influences  the  result.  Sir  Spencer  Wells,  Keith,  and  others, 
have  removed  tumours  successfully  when  weighing  70, 
80,  and  100  lbs. 

Goodell  has  recorded  a  successful  case  in  which  the 
tumour  weighed  112  lbs.;  Cullingworth*  removed  one— 
probably  the  largest  on  record — which  weighed  150  lbs., 
but  the  patient  died. 

It  would  be  interesting  to  be  able  to  state  definitely 
the  risks  of  operation  in  each  class  of  tumour  ;  this  will 
be  impossible  until  surgeons  feel  disposed  to  accept  some 
definite  method  of  classification,  and  arrange  their  cases 
accordingly.  Speaking  generally,  it  may  be  said  that,  in 
experienced  hands,  the  mortality  varies  from  5  to  10  per 
cent.  Here  and  there  a  few  operators  have  published 
long  runs  of  cases  without  a  death.  This  is  very  en- 
couraging; but  when  large  series  of  cases  are  collected, 
the  average  mortality  I  have  stated  will  be  maintained. 
With  less  experienced  operators  the  mortality  after 
ovariotomy  will  vary  from  15  to  20  per  cent. 

*  Lancet,  1S91,  vol.  i.  p.  999. 


|)art    IX. 
DISEASES  OF  THE  FALLOPIAN    TUBES. 


CHAPTER  XIX. 

THE    FALLOPIAN    TUBES. 

The  Fallopian  tubes  are  continuous  with  the  superior 
angles  of  the  uterus,  posterior  to  the  points  of  attachment 
of  the  round  ligaments.  When  the  tubes  are  straightened, 
each  presents  a  wide  outer  end,  then  gradually  narrows  to 
its  point  of  connection  with  the  uterus;  the  expanded  outer 
end  is  the  iiifundibiilum.  The  average  length  of  each 
tube  is  lo  cm. ;  not  infrequently  one  tube  is  longer  than 
its  fellow  :  the  difference  in  length  sometimes  amounts  to 
I  cm.  The  inner  or  uterine  third  of  the  tube  is  narrower 
than  the  outer  two-thirds,  and  is  sometimes  tortuous,  and 
varies  in  thickness  from  2  to  4  mm.  The  outer  segment, 
or  ampulla,  near  the  ostium,  varies  from  7  to  10  mm. 
The  thickness  of  the  walls  of  the  tube  varies  inversely 
with  the  size  of  its  lumen. 

Each  tube  occupies  the  free  border  of  the  broad  liga- 
ment ;  the  isthmus  is  directed  outwards  and  slightly 
upwards,  but  the  ampulla  descends,  passes  behind  and 
external  to  the  ovary,  then  turns  its  ostium  upwards,  so 
that  the  fimbriae  are  in  immediate  contact  with  this  gland. 

The  tube  is  mainly  composed  of  unstriped  muscle 
fibre,  continuous  with  that  of  the  uterus,  and  arranged  in 
an  outer  longitudinal  and  an  inner  circular  layer.  Loose 
connective  tissue  intervenes  between  the  muscular  layer 
and  the  peritoneum,  which  invests  it  on  two-thirds  of  its 


2  24         Diseases  of  the  Fallot /an  Tubes. 

circumference.  The  lumen  of  the  tube  is  Hned  with 
mucous  membrane,  covered  with  columnar  ciliated 
epithelium.  On  slitting  open  the  tube,  the  mucous  mem- 
brane will  be  found  disposed  in  longitudinal  folds,  or  plicce; 
when  traced  outwards,  they  will  be  found  to  increase  in 
thickness  on  approaching  the  end  of  the  tube,  and  at  the 
ostium  they  will  be  found  to  dichotomise  and  become 
continuous  with  the  fimbrire  which  constitute  so  con- 
spicuous a  feature  of  this  end  of  the  tube. 

Tlie  aRxloniiiial  ostium. — No  part  of  the  Fal- 
lopian tube  is  so  variable  in  form  as  this.  Morphologically, 
it  represents  the  anterior  end  of  MuUer's  duct.  Accord- 
ing to  our  present  knowledge,  the  duct  is  at  first  closed 
anteriorly,  but  at  an  early  date  it  undergoes  cleavage  to 
form  the  ostium,  and  thus  to  communicate  with  the  peri- 
toneal cavity  (ccelom).  Running  from  the  ovarian  border 
of  the  ostium  to  the  ovary,  and  occupying  the  intervening 
free  border  of  the  mesosalpinx,  there  is  a  structure  known 
as  the  tubo-ovarian  ligament  traversed  by  a  longitudinal 
furrow,  which  causes  it  to  resemble  a  long  narrow  leaf. 
This  represents  that  portion  of  Mtiller's  duct  opened  out 
along  the  line  of  cleavage.  Frequently  it  is  fringed 
laterally  with  small  fimbri?e,  sometimes  continuous  with, 
but  frequently  distinct  from,  the  plicoe  in  the  tube.  The 
fimbriae  around  the  ostium  have  been  carefully  investi- 
gated by  Richard.'^  He  demonstrated  them  to  be  con- 
tinuous with  the  folds  of  mucous  membrane  within  the 
tube. 

Doranf  has  studied  them,  and  points  out  that  "careful 
examination  of  the  grooves  between  the  plicce  will  enable 
the  observer  to  trace  the  particular  intra-tubal  plica  to 
which  each  fimbria  belongs.      There  is  another  order,  so 


*   These  Anatomie  des  Trompes  de  V  Utenis  chez  la  Femme,  1851. 
^  Trans.  Obstet.  Soc,  London,  vol.  xxxi.  p.  344  ; 


ACCESSOKV    OSTIA.  225 

to  speak,  of  secondary  plicae  which  spring  from  the  sides 
of  the  primary  pliciXi  forming  the  fimbriae.  They  give 
rise  to  the  arborescent  appearance  seen  in  microscopic 
sections  of  the  tube  at  the  ostium.  On  the  other  hand, 
the  two  divisions  of  a  primary  fimbria  may  join 
again,  as  is  often  seen,  above  the  ostium,  within  the 
canal." 

As  the  fimbriae  represent  luxuriant  folds  of  mucous 
membrane  projecting  beyond  the  tube,  we  must  study  the 
boundary  line,  where  they  bulge  beyond  the  serous  mem- 
brane. When  the  peritoneum  is  traced  along  the  tube  to 
the  ostium  it  will  be  found  to  suddenly  terminate  and 
form  a  sharp  line.  Occasionally,  however,  the  peritoneum 
extends  for  a  variable  distance  on  the  fimbriae.  The 
sudden  termination  of  the  peritoneum  on  the  tube 
occasionally  produces  a  circular  constriction,  and  indi- 
cates the  spot  where  the  circular  fibres  of  the  tube  ter- 
minate. The  fringed  portion  of  the  tube  beyond  is  the 
infufidibulum. 

The  ostium  varies  much  in  shape  and  size,  as  well  as  in 
the  number  and  degree  of  development  of  the  fimbriae  not 
only  around  it,  but  along  the  tubo-ovarian  ligament. 
Even  accessory  ostia  and  tufts  of  fimbriae  are  occasionally 
present. 

The  first  systematic  description  of  accessory  ostia  to 
the  Fallopian  tubes  we  owe  to  Richard.*  He  found  five 
examples  in  thirty  females.  Two  of  the  cases  had  two 
accessory  ostia  in  one  tube  ;  one  of  these  specimens  was 
a  foetus  at  term.  The  figure  illustrating  this  specimen  is 
reproduced  by  Farre  in  his  classical  article,  Uterus,  in 
Todd's  CyclopcEiiia.  Since  Richard  drew  attention  to  the 
malformation,  several    observers   have   recorded    cases. 


*  "Pavilions   Multiples  Rencontres  sur  des  Trompes    Uterines  ;  " 
Gaz.  Med.  de  Paris,  1851. 


2  26         Diseases  of  the  Fallopjaj^  Tubes. 

The  best  cacconnt  is  furnished  by  Doran,^  ^vho,  in  the 
course  of  an  examination  of  i,ooo  uterine  appendages 
between  1878  and  1886,  met  with  only  five  examples  of 


ACCE.5S0RY    OSTIUM 


Fig.  64. — Fallopian  Tube,  with  an  Accessory  Ostium. 

malformed  tubes.  Five  out  of  six  of  the  cases  were 
removed  in  the  course  of  operations  performed  at  the 
Samaritan  Hospital,  London.  One  specimen  w^as 
obtained  from  a  malformed  foetus. 

In  the  specimens  examined  by  Richard  the  accessory 

*  "  Malformations  of  the  Fallopian  Tube  ;  "  Tra?]s.  of  the  Obstetrical- 
Society,  Lo?ido7i,  vol.  xxviii.  p.  171. 


The  Hydatid  of  Morgacni.  227 

ostia  communicated  with  the  interior  of  the  tube,  but 
Doran  has  shown  that  accessory  fimbriae  may  be  present 
unassociated  with  an  abnormal  orifice  in  the  tube ; 
further,  an  accessory  ostium  surrounded  by  fimbriae, 
and  a  pedunculated  tuft  of  fimbriae  unconnected 
with  an  accessory  opening,  may  occur  on  the  same 
tube. 

Accessory  ostia  with  fringes  3.nd.  pedunculated accesso7y 
Umbrice^  without  a  supernumerary  ostium,  are  by  no  means 
rare.  Figs.  64  and  65  are  from  specimens  which  came 
under  my  notice.  The  example  sketched  in  Fig.  65,  b, 
possessed  two  abnormal  openings. 

Pedunculated  tufts  of  fimbria  are  probably  derived 
from  Kobelt's  tubes.  When  describing  the  parovarium 
attention  was  drawn  to  the  small  pedunculated  cysts  so 
frequently  found  at  its  anterior  end,  and  known  as 
Kobelt's  tubes.  Some  of  these  small  cysts  rupture,  and 
instead  of  a  stalked  cyst  we  find  a  pedunculated  tuft  of 
fimbriae.  The  cysts  sometimes  appear  as  if  growing 
from  the  wall  of  the  tube,  and  I  have  little  doubt  that 
the  stalked  tufts  of  accessory  fimbriae  originate  in  simi- 
larly displaced  Kobelt's  tubes.  A  specimen  which 
supports  this  view  is  sketched  in  Fig.  65,  c.  A  small 
cyst,  furnished  with  a  small  tuft  of  fimbriae,  Hes  on  the 
tube  in  such  a  manner  that  it  seenis  to  grow  from  the 
tube,  but  the  pedicle  could  be  easily  under  the  peritoneum 
until  it  was  lost  in  the  parovarium. 

The  liydatid,  or  cyst  of  Morg^ag^iii. — This  term 
is  applied  to  small  stalked  cysts,  attached  to  the  fimbriae, 
and  in  some  instances  to  the  tube  itself  It  is  rarely 
larger  than  a  pea.  .  Sometimes  it  is  represented  by  a  tuft 
of  fimbriae  supported  on  a  long  pedicle.  Occasionally 
the  pedicle  of  the  cyst  is  furnished  with  a  small  tuft  of 
fimbriae.  The  true  hydatid  must  not  be  confounded 
with  stalked  cysts  so  frequently  found  associated  with 
p  2 


CYST    WITH 

FIMBRI/E 


Fig  6s  —A,  Pedunculated  Accessory  Fimbriae,  b,  Two  Accessory  Ostia  on 
one  Fallopian  Tube,  c,  Pedunculated  Cyst  from  the  Parovarium,  lying 
athwart  the  Tube  ;  it  possesses  a  tiny  tuft  of  fimbriae. 

p.p.,  Pedunculated  tuft  of  fimbria  ;  O,  normal  ostium  ;  O'  O',  accessory  osHa. 


The  Mucous  Membrane  of  the  Tubes.     229 

the  parovarium.  Ballantyne*  and  Williams  have  care- 
fully investigated  the  frequency  with  which  the  true 
hydatid  is  present.  They  found  stalked  cysts  present 
in  57  per  cent,  of  specimens  examined.  The  true 
Morgagnian  cyst  was  present  in  8  per  cent,  in  adults, 
and  in  27  per  cent,  of  fcetuses  and  infants.  The  total 
number  of  tubes  examined  was  ninety-four  pairs  from 
adults,  eleven  pairs  from  foetuses,  and  five  pairs  from 
children.  The  structural  differences  between  the  t\vo 
forms  are  important.  According  to  Ballantyne  and 
Williams,  the  true  Morgagnian  cyst  "  is  lined  by  a 
mucosa  with  simple  folds,  covered  by  a  single  layer  of 
ciliated  columnar  epithelial  cells ;  its  wall  is  ahvays 
composed  of  muscular  fibres,  arranged  circularly  and 
longitudinally ;  its  outer  membrane  is  the  peritoneum  ; 
its  stalk  is  always  muscular,  and  its  contents  consist  of 
clear  limpid  fluid ; "  whereas  the  small  pedunculated 
cysts  of  the  parovarium  have  fibrous  stalks  and  walls ; 
the  interior  of  such  cysts  is  lined  by  cubical  epithelium. 

The  uiucoiis  lueiubraue  ol  the  Fallopian 
tube. — The  tubal  mucous  membrane  is  thrown  into 
longitudinal  folds,  or  plicae,  which  are  most  numerous  in 
the  wide  portions  of  the  tubes.  In  the  isthmus  they  are 
small  in  size  and  few  in  number,  and  at  the  uterine  orifice 
the  mucous  membrane  is  continuous  with  that  lining  the 
uterus.  The  epithelium  is  columnar  in  shape,  and  fur- 
nished with  delicate  cilia.  It  is  usually  stated  that  the  tube 
is  devoid  of  glands,  but  how  far  this  statement  represents 
the  actual  state  of  affairs  is  well  open  to  question.  The 
structure  of  the  mucous  membrane  of  this  tube  has  been 
so  carefully  and  systematically  examined  by  competent 
experts  that  the  mere  facts  are  beyond  dispute,  but  they 
will   admit   of  a  different    interpretation  to  that  usually 

*  Brit.  Med.  Journal,  Jan.  24th,  1891. 


■30 


Diseases  of  the  Fallopian  Tubes. 


placed  upon  them,  and  arguments  and  facts  will  now  be 
advanced  in  order  to  show  that  the  folds  in  the  tubal 
mucous  membrane  are  glands. 

A  gland  in  its  simplest  form  is  a  sac  or  tube  derived 
from  the  invagination  of  epithelium.  Larger  and  more 
complicated  glands  may  be  derived  from  this  as  the 
result  of  secondary  outgrowths  from  the  primary  sac 
(Fig.  66). 

The  glandular  nature  of  the  recesses  in   the  human 


Fig.  66. — Simple  forms  of  Glands. 


Fallopian  tube  could  not  be  settled  without  an  appeal 
to  the  characters  of  the  mucous  membrane  in  the 
Fallopian  tube  of  other  mammals,  and  the  corresponding 
section  of  the  oviducts  in  lower  vertebrata.  Take,  for 
instance,  the  elaborate  work  required  of  the  mucous 
membrane  in  a  bird's  oviduct,  not  only  for  producing  an 
albuminous  investment  for  the  egg,  but  the  subsequent 
deposition  of  a  calcareous  coat  exhibiting  a  definite 
structure.  Yet  the  mucous  membrane  is  simply  thrown 
into  longitudinal  folds  resembling  the  so-called  rugae  or 
plicae  of  the  human  Fallopian  tube. 

The   simple  construction  of  the  mucous   membrane 
in    the    avian    oviduct    is    well    calculated    to     excite 


The  Fallopian  Glands. 


23t 


astonishment  when  compared  with  the  internal  lining  of 
the  oviducts  of  frogs,  salamanders,  lizards,  and  tortoises.^ 
In  these  animals  the  mucous  membrane  of  the  oviducts  is 
richly  beset  with  complex  glands. 

In    many   mammals    the    mucous    membrane  of  the 


■'^ 


\ 


fvi^^. 


Fig,  67. — Transverse  Section  of  the  Fallopian  Tube  of  a  Macaque  Monkey 
(Macactis  rliesics). 


tubes  is  far  more  complex  than  in  the  human  female.  The 
microscopic  appearance  of  a  transverse  section  of  the 
tube  from  a  Macaque  {Macacus  rhesus),  taken  from  near 
the  middle  of  the  tube,  is  represented  in  Fig.  67. 

It  shows  very  well  the  cluster-like  arrangement  of  the 
glandular  acini,  each  presenting  a  single  layer  of 
large  regular  sub-columnar  epithelium.      An  examination 


232         Diseases  of  the  Fallopian  Tubes. 

of  a  large  number  of  specimens  shows  that  in  the  middle 
of  the  tube  the  mucous  membrane  is  most  complicated ; 


Fig.   68. — Recess  of  the  Tubal  Mucous  Membrane  of  the    Panolian  Deer 
{Ceti'us  eldi).     {T7-ans.  Ohstet.  Soc.) 


in   the  section  near   the  uterus   it  is  simplest,  and    the 
number    of   acini,    or    recesses,  varies   with    age.     The 


The  Fallopian  Glands.  233 

different  sketches  of  the  tubal   mucous  membrane  given 
by  various  authors  are  thus  explained. 

The  Fallopian  tubes  of  ruminants  are  very  thin  and 
narrow  ducts,  but  the  mucous  membrane  reaches  a  high 
degree  of  complexity,  and  is  richly  beset  with  glands 
of  a  racemose  type.     A  sketch  of  a  recess  from  the  tube 


Fig.    69. — Transverse    Section    of  the    Fallopian   Tube   of  a   Woman.     (After 

Schenck.) 


of  the  Panolian  deer  {Cervics  eldi)  is  given  in  Fig.  68.  The 
recesses  are  lined  with  a  single  layer  of  regular  columnar 
epithelium.  These  recesses  are  so  numerous  that  as 
many  as  twelve  may  be  counted  in  one  section  of  a  tube  ; 
they  extend  around  the  whole  circumference.  Mucous 
membrane  as  complex  as  this  occupies  the  Fallopian 
tube  of  the  Malay  bear. 

A  very  instructive  sketch  of  the  tubal  mucous  mem- 
brane of  a  woman  is  reproduced  in  Fig.  69,  because  it 
shows,  from  an  independent  worker,  that   these  ridges 


234         Diseases  of  the  Fallopian  Tubes. 

and  folds  are  disposed  in  the  tubes  on  the  same  principle 
as  the  glands  in  the  uterus.  The  most  instructive  age  at 
which  to  observe  the  Fallopian  glands  is  in  the  tubes  of 
the  foetus  at  birth.  At  this  date  they  attain  their  greatest 
complexity,  and  specimens  even  more  luxuriant  than 
those  shown  in  the  drawing  of  the  tubal  mucous  mem- 
brane of  the  Macaque  (Fig.  67)  are  not  infrequently 
found.  The  probable  function  of  the  Fallopian  glands  is 
to  provide  an  albuminous  fluid  for  the  ovum  as  it  tra- 
verses the  Fallopian  tube. 

It  is  well  to  emphasise  the  point  that  the  micro- 
scopical characters  of  the  mucous  membrane  do  not 
admit  of  any  difference  of  opinion.  The  question  is  one 
of  interpretation. 


-60 


CHAPTER  XX. 

SALPINGITIS      AND      ITS      EFFECTS  :      PYOSALPJNX. 

Salpingitis,  or  iiiflaiiimatioii  of  the  Fallo- 
pian tube,  is  nearly  always  secondary  to  inflammation 
of  the  genital  tract. 

The  chief  causes  are  septic  endometritis,  gonorrhoea, 
and  cancer  of  the  uterus  ;  exceptional  causes  are  tubercle 
and  actinomycosis. 

The  changes  in  the  tubes,  induced  by  septic  endo- 
metritis and  gonorrhoea,  are  nearly  identical,  ai^.d  the 
effects  produced  may  be  studied  in  four  stages : — 

1.  T/ie  acute  stage,  ending  with  closure  of  the  abdominal 

ostium. 

2.  The  modes  by  which  the  tube  is  closed, 

3.  Pyosalpinx  and  its  effects. 

4.  Hydros  alp  ijix. 

First  stage. — When  inflammation  extends  from  the 
vagina  into  the  uterus,  and  passes  into  the  tubes,  the 
tubal  tissues  become  soft,  succulent,  swollen,  and  friable. 
The  fimbrice  are  also  swollen  and  succulent.  When  the 
tube  is  slit  up,  the  mucous  membrane  will  be  found 
covered  with  glutinous  pus.  If  the  tube  be  gently 
squeezed  before  it  is  opened,  a  few  drops  of  pus  will 
exude  from  the  ostium.  Opportunities,  of  examining 
tubes  in  this  early  stage  have  only  occurred  to  me  twice  : 
once  in  a  young  prostitute,  with  gonorrhoea  and  sudden 
acute  peritonitis  beginning  in  the  pelvis.  The  abdomen 
was  opened  and  the  tubes  exposed ;  pus  was  seen  drop- 
ping from   their  unclosed  ends.     The  second  case  was 


236         Diseases  of  the  Fallopian  Tubes. 

more  severe.  The  mucous  membrane  rapidly  became 
gangrenous.  The  case  was  that  of  a  woman  forty-three 
years  of  age,  with  a  sloughing  uterine  myoma.  The 
myoma  was  removed,  but  the  septic  mucous  membrane 
necrosed.  The  necrosis  extended  to  the  mucous  mem- 
brane of  the  tubes,  and  the  dead  tissue  was  found  pro- 
jecting into  the  peritoneum  from  the  unclosed  ostia  of 
the  tubes  ;  it  had  set  up  rapidly  fatal  peritonitis  (Fig.  70). 

Second  stage. — This  commences  with  closure  of  the 
abdominal  ostium  :  a  process  of  great  importance,  and 
one  that  requires  careful  consideration.  Doran*  has 
clearly  shown  that  the  ostium  may  be  occluded  by  peri- 
metritis or  salpingitis.  Perimetritis  indicates  inflamma- 
tion of  the  pelvic  peritoneum.  It  may  be  secondary  to 
salpingitis,  endometritis,  uterine  cancer,  or  a  sohd  tumour 
or  cyst  of  the  pelvis.  One  of  its  most  constant  effects  is 
the  formation  of  adhesions,  due  to  organisation  of  inflam- 
matory products,  in  the  neighbourhood  of  the  abdominal 
ostium  of  the  tube.  The  method  by  which  the  tube  is 
closed  in  perimetritis  is  very  simple.  Inflammatory 
matters  effused  among  and  in  the  tissues  of  the  fimbriae 
cause  them  to  swell,  adhere  together,  and  often  to  the 
ovary.  The  effused  material  organises  and  binds  the 
agglutinated  fimbriae  to  adjacent  structures,  such  as  the 
ovary,  broad  ligament,  pelvic  peritoneum,  uterus,  or 
rectum,  and  mechanically  seals  the  ostium. 

Salpingitk  closure  of  the  ostium  is  a  slow  but  interest- 
ing process.  It  takes  place  in  the  following  manner  : — 
The  Fallopian  fimbriae  may  be  regarded  as  luxuriant  pro- 
trusions of  the  mucous  membrane  beyond  the  ostium. 
When  inflamed,  they  enlarge  greatly.  As  the  inflamma- 
tion extends  into  the  muscular  coat  of  the  tube,  it  becomes 


*  "  On  Closure  of  the  Ostium  in  Inflammation  and  Allied  Diseases 
of  the  Fallopian  Tube;  "  Trans.  Obstet.  Soc.,  1890. 


Fig     70  —Section   of  a  Uterus   from  which  a  Gangrenous  Myoma  had  been 

removed.     {Trans.  Obstet.  Soc.) 

The  mucous  membrane  had  become  gangrenous,  and  infecrive  material  had  leaked  into  the 

peritoneum  through  the  unclosed  ostmm. 


238  jDiS EASES    OF    THE    FaLLOPIAN    TuBES. 

lengthened,  and  gradually  bulges  over  the  fimbriae,  until 
the  ostium  presents  a  rounded  orifice,  instead  of  its  usual 
fringed  appearance.  Eventually  these  rounded  margins 
contract,  narrow  the  orifice,  and  cohere,  giving  it  a 
smooth,  rounded  end,  not  unlike  a  sea-anemone  with  its 
tentacles  retracted  (Fig.  71).  On  slitting  up  such  a 
tube  the  fimbriae  will  occasionally  be  found  neatly  folded 
up  within  it  (Fig.  72). 

The  fimbriae  are  not  always  so  neatly  retracted  as  in 
Fig.  72.  A  few  of  them  may  be  nipped  by  the  contracting 
ostium,  and  be  left  projecting  (Fig.  73). 

After  closure  of  the  ostium,  pus  or  mucus  will  accu- 
mulate within  the  tube,  for  the  inflamed  mucous  mem- 
brane obstructs  the  uterine  orifice,  and  the  intervening 
section  will  distend  into  a  legume-shaped  cyst,  called 
hydrosalpinx  or  pyosalpinx,  according  to  the  nature  of 
the  retained  fluid.  Doran  has  pointed  out — and  my  own 
observations  are  in  complete  harmony  with  his — that  peri- 
metritis, when  secondary  to  salpingitis,  will  assist  the 
latter  process  in  occluding  the  ostium.  In  many  speci- 
mens of  salpingitic  occlusion  of  the  tube,  a  small  pedun- 
culated cyst  is  often  present.  Whether  this  is  the  so- 
called  hydatid  of  Morgagni  or  a  cyst  arising  in  a  Kobelt's 
tube,  I  am  unable  to  decide. 

Coincidently  with  occlusion  of  the  ostium,  other 
changes  are  taking  place,  ks,  the  tube  enlarges  when 
inflamed,  it  spreads  out  the  two  layers  of  the  mesosal- 
pinx, and  often  burrows  between  them  towards  the  ovary. 
As  the  tube  thickens  it  also  lengthens  ;  but,  being  held 
by  the  tubo-ovarian  fimbria  and  the  mesosalpinx,  it  will 
often  become  markedly  tortuous.  The  majority  of  sal- 
pingitic tubes  burrow  between  the  layers  of  the  meso- 
salpinx until  the  ovary  and  tube  are  in  contact.  This 
process  is  called  "  obliteration  of  the  mesosalpinx."  It 
is    occasionally    prevented    by    the    connective    tissue 


AMPULLA 


Fig.  71.— Salpingitic  Closure  of  the  Ostium. 


FRINGES 


Fig.  72.— Salpingitic  Closure  of  the  Ostium. 


FRINGES 


Fig.  73- — Salpingitic  Closure  of  the  Ostium. 
M,  A  pedunculated  cyst. 


!40 


Diseases  of  the  Fallopian  Tubes. 


between  the  tube  becoming  infiltrated  with  inflammatory 
products.  In  some  cases  the  tube  and  ovary  are  drawn 
together  by  adhesions,  and  on  dividing  these,  the  tube 
and  ovary  are  easily  separable.  In  such  examples  the 
mesosalpinx  is  merely  crumpled,  not  obliterated.    These 


Fig.  74. — Transverse  Section  of  the  Tube  and  Mesosalpinx,  in  which  the  latter 
is  infiltrated  with  inflammatory  products,  secondary  to  gonorrhosal  salpingitis. 


processes  have  an  important  relation  to  the  formation  of 
tubo-ovarian  abscesses.  Salpingitic  occlusion  of  the 
ostium  is  a  slow  process,  and  this  accounts  for  the 
frequent  existence  of  perimetritis  as  a  complication. 

Before  proceeding  to  discuss  the  gross  changes  which 
occur  subsequent  to  closure  of  the  abdominal  ostium,  it 
will  be  convenient  to  consider  the  minuter  changes  which 
characterise  infective  salpingitis.     The  most  instructive 


Cell  Changes  in  Salpingitis.  241 

specimens  are  obtained  from  patients  in  whom  sal- 
pingitis is  secondary  to  gonorrhoea,  and  who  have 
exhibited  evidence  of  tubal  disease  for  many  months. 
On  dividing  the  ampulla  of  such  a  tube,  it  will  be  found 
greatly  thickened  in  all  its  coats — serous,  muscular,  and 
mucous — ^especially  the  last,  which  will  often  present  a 
closely  plicate  arrangement,  resembling  the  arbor  vitae  of 
the  cerebellum.  When  shghtly  magnified,  the  so-called 
plicae  of  the  tube  are  seen  to  be  swollen,  and  almost  fill 
the  lumen  of  the  tube,  whilst  the  mesosalpinx  is  occupied 
by  inflammatory  exudation,  in  which  the  vessels  seem  to 
be  firmly  embedded  (Fig.  74). 

It  is  upon  such  tubes  that  the  following  remarks 
relative  to  cells  and  micro-organisms  are  mainly  based. 

Without  assuming  that  it  is  proved  that  pus  is  always 
due  to  micro-organisms,  there  seems  Httle  room  for  doubt 
that  gonorrhoea  and  septic  endometritis  are  due  to  the 
presence  of  such  bodies,  and  these  two  affections  are  the 
most  frequent  cause  of  salpingitis.  When  a  healthy 
Fallopian  tube  is  examined  in  transverse  section  by 
means  of  a  microscope,  we  distinguish  easily  the  serous 
and  muscular  coats  of  the  tube,  and,  standing  upon  these, 
the  so-called  plicae  formed  by  the  mucous  coat.  These 
pHcae  consist  of  a  delicate  frame-w^ork  of  connective  tissue, 
fringed  with  columnar  ciliated  epithelium  on  the  free 
surface.  Delicate  strands  of  unstriated  muscle  cells  may 
be  distinguished  near  the  base  of  the  epithelium,  and  in 
the  middle  of  the  fold  are  many  capillaries.  As  a  rule,  a 
few  leucocytes  may  be  seen  scattered  among  the  meshes 
of  the  connective  tissue.  When  sections  are  prepared 
from  tubes  which  have  been  for  some  months  the  seat  of 
salpingitis,  the  appearances  are  very  different.  The  plicae 
are  swollen  to  twice  or  thrice  the  usual  size,  and  all  the 
details  of  their  structure  obscured  by  an  innumerable 
host  of  cells  of  various  sizes.     In  many  places  the  limiting 

Q 


242         Diseases  of  the  Fallopian  Tubes. 

epithelium  is  lost ;  in  others  it  can  be  detected  disturbed 
and  disarranged,  here  and  there  seemingly  held  in 
position  by  some  glutinous  material.  In  mild  cases  this 
peculiar  cell  infiltration  is  limited,  and  does  not  involve 
the  whole  plica,  but  in  very  diseased  specimens  the  cells 
are  not  limited  to  the  plicae^  but  involve  the  muscular 
coat,  and  extend  into  the  connective  tissue  of  the 
mesosalpinx  (Plate  IV.). 

In  order  to  more  thoroughly  investigate  the  nature  of 
this  cell  infiltration,  I  selected  some  cases  of  salpingitis 
which  had  been  under  my  care,  and  which  I  knew  to  be 
secondary  to  gonorrhoea.  On  removing  the  tubes,  pieces 
w^ere  cut  out  and  dropped  into  absolute  alcohol  within 
fifteen  minutes  of  their  abstraction  by  operation,  and 
before  they  had  lost  their  tissue  life.  After  careful 
hardening,  sections  were  stained  in  logwood,  alum  car- 
mine, methyl  violet,  and  the  like.  The  appearances  now 
to  be  described  came  out  in  clearest  detail  in  the  logwood 
preparations.  In  some  specimens  the  cells  were  packed 
so  closely  as  to  produce  a  mosaic,  but  near  the  free 
borders  of  the  plicse  the  best  opportunities  occurred  for 
distinguishing  the  contours  of  individual  cells.  The  cells 
w^ere  of  various  size  and  shape ;  in  most  the  nucleus  was 
so  large  that  on  superficial  examination  it  would  be  mis- 
taken for  the  cell  itself.  On  carefully  focussing  such  a 
cell,  under  a  moderate  power  (\  in.),  a  delicate  ring  of 
unstained  protoplasm  could  be  distinguished.  Here  and 
there  cells  with  moderate  nuclei  and  a  large  amount  of 
unstained  protoplasm  were  seen.  These  were  not  nu- 
merous. Under  a  high  power  (yV  in.  lens)  the  following 
facts  were  noted  : — i.  The  greater  proportion  of  the  cells 
had  large  nuclei  and  a  small  rim  of  unstained  protoplasm. 
Many  of  the  nuclei  contained  three,  four,  and  even  six 
nucleoli,  and  sometimes  an  aster.  2.  Others  had  a  large 
elliptical  nucleus,  and  in  their  general  features  resembled 


^^, 


/ 


JS^w- 


l-^if-^ 


Plate    IV'. — A   Plica  of  the    Tubal    Mucous    Membrane,   in   section.     Highly 

magnified.    (From  a  case  of  gonorrhoea!  salpingitis.) 

The  epithelium  persists  in  the  recesses. 


Amcebic   Warfare. 


243 


PHAGOCYTES 


the  epithelioid  cells  so  commonly  seen  in  tubercle.  The 
protoplasm  of  these  cells  contained  granular  bodies 
arranged  in  pairs,  and  collected  in  "  groups  of  pairs,"  like 
the  diplococci  which  have  been  described  in  gonorrhceal 
discharges.  3.  The  largest  cells  were  nearly  transparent, 
scarcely  taking  the  stain,  and  with  a  circular  nucleus 
small  in  proportion  to  the  size  of  the  surrounding  proto- 
plasm. These  cells  in  nearly 
every  instance  contained  groups 
of  diplococci-like  bodies.  The 
characters  of  these  cells  are 
shown  in  Fig.  75. 

The  new  and  important  light 
shed  on  the  pathology  of  mflam- 
mation  by  the  discovery  of  intra- 
cellular digestion  tends  to  show 
that  inflammation  is  in  essence  diplococci 
a  struggle  between  irritant  bodies 
of  various  kinds  and  leucocytes 
— a  struggle  which  may  be  termed 
aiiiGBbic  warfare.  Since 
Metschnikoff  made  us  acquainted 
with  the  aggressive  powers  of 
leucocytes  and  the  "wandering 
cells  of  the  mesoderm,"  many  have  confirmed  his  obser- 
vations ;  and  a  recent  contribution  to  this  subject  by  Dr. 
Armand  Ruffer,  on  the  "  Phagocytes  of  the  Alimentary 
Canal,"  is  of  great  interest.  Phagocytes.,  or  "  fighting 
cells,"  are  of  two  kinds.  Microphages.,  mono-  or  poly- 
nucleated  cells,  are,  as  a  matter  of  fact,  large  leucocytes. 
These  have  long  been  familiar  to  histologists  as  epitheloid 
cells.  Macrophages  are  large  mono-nucleated  cells,  also 
developed  from  leucocytes.  Microphages  and  macro- 
phages are  each  able  to  engulf  and  rapidly  digest  micro- 
organisms; Macrophages  are  able  to  engulf  microphages 
Q  2 


MACROPHAGES 

Fig.  75.— Aggressive  Cells  from 
the  Mucous  Membrane  of  a 
chronically  inflamed  Fallo- 
pian Tube. 


244         Diseases  of  the  Fallopian  Tubes. 

and  destroy  them.  This  apparently  cannibalistic  process 
seems  to  take  place  when  the  microphage  is  weakened.* 
The  cells  found  in  the  infiltrated  mucous  membrane  of  a 
Fallopian  tube  secondary  to  gonorrhoea  belong  to  these 
two  types  of  aggressive  phagocytes. 

I*yosalpiiix. — In  severe  cases  of  salpingitis  after 
occlusion  of  the  abdominal  ostium,  accompanied,  as  is 
usual,  with  obstruction  of  the  uterine  end  of  the  tube,  the 
pus  is  as  securely  locked  up  in  the  tube  as  it  would  be 
in  a  deep-seated  abscess,  and  it  follows  the  course 
of  an  abscess.  The  walls  of  the  tube,  stretched 
by  the  accumulating  pus,  gradually  thin,  and  the 
inflamed  tube  becomes  adherent  to  surrounding  struc- 
tures— ovary,  uterus,  rectum,  intestine,  or  broad  liga- 
ment. The  wall  of  the  tube  continues  to  thin  until, 
on  some  slight  exertion,  it  bursts.  If  the  pus  be  dis- 
charged into  the  peritoneal  cavity,  it  establishes  rapidly 
fatal  infective  peritonitis.  Left  pyosalpinx  is  very  prone 
to  open  into  the  rectum.  When  a  pyosalpinx  lies  in 
contact  with  bowel,  the  pus  it  contains  becomes  foetid, 
due  to  diffusion  of  intestinal  gases. 

The  accuniulation  of  pus  in  the  Fallopian  tubes  leads 
sometimes  to  great  distension,  so  that  they  become  con- 
verted into  legume-shaped  cysts,  measuring  i6  cm.  in 
length,  and  lo  cm.  in  circumference.  Such  tubes  will 
rise  out  of  the  pelvis,  and  form  tumours  rising  above  the 
pelvic  brim,  and  even  reaching  as  high  as  the  umbilicus. 
A  large  pyosalpinx  has  often  been  mistaken  for  an 
ovarian  cyst.  Fallopian  tubes  of  this  size  are  contained 
in  a  serous  capsule  formed  by  the  thickened  tissues  of 
the  broad  ligament. 

When  examined   microscopically,  the  true   tissues  of 


*  Quarterly  Journal  of  the  Microscopical  Society,  vol.  xxx.  part  4, 
February,  1890. 


FVOSALPINX. 


245 


the  tubes  are  found  distended  and  thinned,  except  in 
places  where  they  are  infiltrated  with  inflammatory  pro- 
ducts. 


RECTUM 


Fig.  76. — Large  Pyosalpinx. 

The  tube  communicates  with  an  abscess  in  the  ovary  (tubo-ovarian  abscess),   and  each 
communicates  with  the  rectum. 


This  alteration  in  the  tissues  is  sufficient  to  distinguish 
them  from  distension  of  bicornuate  uteri,  which  are  some- 
times confounded  with  them. 

The  JMuseum  of  the  Royal  College  of  Surgeons 
contains  two  specimens  which  illustrate  this  very  well. 
They  are  two  cysts,  resembling  huge  legumes  :  they  have 


246 


Diseases  of  the  Fallopian  Tubes. 


thick  muscular  walls  (Fig.  77).  At  the  time  of  removal 
the  right  one  weighed  seventy-five  and  the  left  one 
twenty-two  ounces.  Each  contained  thick  mucus.  Sir 
Spencer  Wells,  who  removed  them,  believes  that  they 
are  distended  Fallopian  tubes.  The  patient,  a  young 
woman,  recovered  from  the  operation,  and  has  con- 
tinued to  menstruate  regularly  ever  since. 


Fig.  77.— Two  legume-shaped  Cysts  supposed  to  be  Fallopian  Tubes.  (Museum 
Royal  College  of  Surgeons.) 


It  is  a  fact  important  to  be  remembered  that  when  a 
Fallopian  tube  becomes  distended  not  only  by  fluid  ac- 
cumulations, but  by  an  impregnated  ovum  developing 
within  it,  the  walls  of  the  tube  gradually  thin.  In  this 
respect  the  tubes  are  in  striking  contrast  with  the  uterus. 
Whenever  the  uterine  cavity  becomes  distended  by  a 
developing  embryo,  the  accumulation  of  retained  mucus, 
or  a  myoma  projecting  into  it,  the  uterine  tissue  hyper- 
trophies.    This  is  true  not  only  in  the  case  of  the  human 


Hydrometra. 


247 


uterus,  but  also  in  that  of  mammals  generall}^  It  fre- 
quently happens  with  bicornuate  uteri  that  the  cervical 
canal  becomes  obstructed,  leading  to  retention  of 
secretions  in  one  or  both  cornua — a  condition  known  as 
hydrometra  when  the  retained  fluid  is  mucus,  and 
pyomeira  when  the  fluid  is  purulent.  An  example  of 
hydrometra  from  a  ewe  is  sketched  in  Fig.  78. 


Cotyledon. 


Fig.    78. — Uterus   of  a   Ewe   distended  with   Mucus  :    Hydrometra, 
(Museum,  Ro^'al  College  of  Surgeons.) 


In  all  such  specimens  the  distended  cornua  had  thick 
muscular  walls  ;  in  all  the  examples  of  distended  Fallopian 
tubes  that  I  have  examined  the  walls  of  the  tubes"  were 
thin,  except  here  and  there  where  the  walls  were  in- 
filtrated with  inflammatory  exudation. 

With  these  facts  for  our  guidance,  let  us  look  anew 
at  Fig.  77,  and  restore  the  legume-shaped  cysts  to  what 
we  may  fairly  believe  to  have  been  their  original  position 
(Fig.  79).  It  will  be  seen  that  these  supposed  Fallo- 
pian tubes  are  dilated  uterine  cornua,  and  the  woman 
from  whom  they  were  removed  had  probably  a  bicornuate 


248 


Diseases  of  the  Fallopian  Tubes. 


uterus,  and,  as  in  the  case  of  the  ewe,  there  had  been  some 
stenosis  of  the  cervical  canal,  or  at  any  rate  obstruction 
to  the  free  escape  of  secretion  which,  being  retained,  led 
to  their  distension.  I  am  persuaded  that  several  speci- 
mens described  as  large  distended  tubes,  in  which  the 


<:ej 


Fig.  79. — The  two  supposed  Fallopian  Tubes  (Fig.  77)  restored  to  their  probable 
natural  relationship. 


walls  were  thick  and  muscular,  were  really  examples  of 
hydrometra  or  pyonietra  in  bicornuate  uteri. 

The  want  of  care  in  distinguishing  between  elongated 
uterine  cornua  and  Fallopian  tubes  has  been  a  fertile 
source  of  error  in  the  comparative  physiology,  as  well  as 
the  comparative  pathology  of  the  uterus  and  Fallopian 
tubes. 

The  tube  does  not  dilate  in  all  cases  of  salpingitis  :  in 
some  the  walls  are  infiltrated  with  inflammatory  products, 


PVOSALPINX  AND    CaNCER.  249 

and  become  thick  and  succulent ;  but  in  such  tubes  the 
muscular  and  mucous  tissues  are  destroyed. 

Pyosalpiiix  in  uteriuc  cancer. — Distension  of 
the  Fallopian  tubes  not  infrequently  accompanies  cancer 
of  the  uterus,  and  in  a  certain  proportion  of  cases  precipi- 
tates the  final  event  by  rupturing  and  producing  peri- 
tonitis. To  Dr.  J.  K.  Fowler*  we  are  indebted  for  this 
addition  to  our  knowledge.  In  A  Contribution  to  the 
Pathology  of  Hydro-  and  Pyo-salpiiix  he  describes  briefly 
fifteen  examples  which  he  met  with  in  the  course  of  three 
years  in  \hQ post-mortem  room  of  the  Middlesex  Hospital. 
Of  these,  pyosalpinx  \vas  associated  with  uterine  cancer 
in  two  instances.  In  one  fatal  peritonitis  w^as  induced 
by  rupture  of  the  pus-containing  tube.  Dr.  Fowler's 
description  is  : — '"  The  right  Fallopian  tube  was  dis- 
tended to  the  size  of  an  ordinary  sausage,  and  contained 
a  quantity  of  pus.  Its  walls  were  considerably  thickened  ; 
the  internal  orifice  was  closed.  At  the  fimbrial  extremity 
the  tube  had  burst  into  the  cavity  of  the  peritoneum. 
The  left  tube  was  normal."  Under  the  heading  "  Re- 
marks," we  find  the  following  : — "  This  case  is  interesting 
from  the  fact  that,  although  the  patient  was  suffering 
from  cancer  of  the  uterus,  death  was  due  to  peritonitis, 
the  result  of  rupture  of  the  dilated  tube." 

The  records  of  the  Middlesex  Hospital,  embodied  in 
the  Reports  annually  prepared  by  the  pathologists  who 
have  succeeded  Dr.  Fowler,  contain  confirmatory  obser- 
vations, and  indicate  that  pyo-  and  hydro-salpinx 
complicate  uterine  cancer  in  the  proportion  of  not  less 
than  ten  per  cent. 

*  Medical  Societfs  Proceedings,  London,  vol.  vii.  p.  441, 


250 


CHAPTER  XXI. 

TUBO-OVARIAN     ABSCESS — HYDROSALPINX 

HiEMATOSALPINX. 

In  this  chapter  the  effects  of  salpingitis  will  be  studied 
when  the  inflammation  extends  to  and  involves  the  ovary, 
as  well  as  the  abnormal  conditions  of  the  tube  which 
follow  upon  complete  occlusion  of  the  ostium. 

Oophoritis  secoii«lary  to  infective  salpin- 
gitis.— When  the  inflammatory  process  extends  to  the 
peritoneum  in  chronic  cases  of  salpingitis,  it  is  sure  to 
involve  the  ovary. 

The  first  effect  is  to  cause  thickening  of  its  capsule, 
and  if  lymph  is  effused  upon  its  surface,  this  may  organise, 
and  extensive  perimetritic  adhesions  result.  The  effects 
of  this  thickening  of  the  capsule  "are  two-fold.  At  first 
it  prevents  the  rupture  of  ripe  ovarian  follicles,  and  the 
tension  gives  rise  to  considerable  disturbance  and  causes 
pain ;  as  the  enlarged  follicles  cannot  discharge  their 
contents,  it  naturally  follows  that  on  section  an  ovary 
which  has  long  been  the  seat  of  perioophoritis  will  be 
found  largely  converted  into  cystic  spaces,  and  two  or 
more  may  become  confluent,  and  form  a  cyst  the  size  of 
a  walnut.  As  such  a  cyst  enlarges  and  makes  its  way  by 
absorption  to  the  surface,  it  not  unfrequently  comes  into 
relation  with,  and  adheres  to,  the  dilated  pus-containing 
ampulla  of  the  corresponding  tube,  which  has  been 
brought  in  contact  with  it  through  the  restraining  influ- 
ence of  the  tubo-ovarian  ligament,  or  by  direct  adhesion  : 
for  the  ovary  and  tube  are  in  contact.     Except  that  the 


TUBO-  O  VA  R I A  N  A  BSCESS. 


251 


tube  and  ovary  become  bound  together,  no  further 
change  ensues  in  the  majority  of  cases,  but  not  infre- 
quently absorption  takes  place,  and  the  dilated  ampulla 
of  the  tube  will  communicate  with  an  enlarged  follicle  or 
cyst  in  the  ovary,  and  thus  give  rise  to  a  tubo-ovarian 
abscess.     The  communication  in  such  cases  is  usually 


Fig.  So. — Tubo-Ovarian  Abscess,  secondary  to  Gonorrhoea. 
*  Adherent  fimbrire. 


small,  and  barely  admits  a  probe  (Fig.  80).  I  have  had 
many  opportunities  of  dissecting  such  specimens.  When 
a  pyosalpinx  or  a  tubo-ovarian  abscess  communicates 
with  the  rectum,  the  pus  is  discharged  by  way  of  the 
anus  at  irregular  intervals,  and  is  accompanied  by 
great  improvement  in  the  "patient's  symptoms.  When  a 
tubo-ovarian  abscess  communicates  with  the  rectum,  it  is 
the  portion  ot  the  abscess  lodged  in  the  ovary  that 
usually  becomes  the  seat  of  fistula  (Fig.  76). 

It  is  worth  noting  that  in  tubo-ovarian  abscesses  the 


252 


Diseases  of  the  Fallopian  Tubes. 


abdominal  end  of  the  tube  is  occluded.  Up  to  the 
present  time  I  have  not  met  with  an  exception  to  this  rule. 
This  indicates  that  the  primary  troul^le  is  in  the  tube 
Pyosalpinx  occurs  frequently  without  an  ovarian  abscess. 
When  ovarian  abscess  occurs  independently  of  salpingitis, 
my  observations  lead  me  to  beHeve  that  it  is  generally 
tubercular. 


Fig.  8i. — Tubo-Ovarian  Abscess.     (Museum,  Royal  College  of  Surgeons.) 

Hydrosalpinx. — The  persistent  course  of  salpingitis 
leading  to  occlusion  of  the  ostium,  though  very  frequent, 
does  not  occur  in  all  cases.  Many  mild  attacks  may  be 
conveniently  described  as  "  catarrh  of  the  tube,"  and, 
like  a  nasal  or  gastric  catarrh,  subside  and  leave  no  trace. 
When  the  inflammation  is  sufficiently  intense  to  seal  the 
ostium,  permanent  damage  results,  and  if,  as  is  so  com- 
monly the  case,  both  tubes  are  affected,  they  remain 
throughout  life  functionless,  and  often  a  source  of  grave 
danger.     In    cases    of  salpingitis    sufficiently  severe    to 


Hydrosalpinx.  253 

occlude  the  ostium,  the  tube  is,  after  the  subsidence  of 
the  intiammation,  in  the  condition  of  a  blocked  ureter  ; 
there  is  no  escape  for  the  fluid  which  is  excreted  by  the 
glands  in  its  walls,  or  for  the  fluid  which  passively  exudes 
into  its  cavity.  It  consequently  forms  a  cyst  by  reten- 
tion. The  contained  fluid  is  more  or  less  colourless  ; 
sometimes  it  has  a  greenish  tinge,  due  to  the  presence  of 
cholesterine.  Frequently  it  is  the  colour  of  chocolate. 
This  condition  is  termed  hydrosalpinx^  and  may  be 
defined  as  a  Fallopian  tube,  diste?tded  with  fluid  in  con- 
sequence of  inflammatory  occlusion  of  its  abdomitial  ostium. 
The  changes  that  arise  in  the  occluded  and  distended 
tubes  are  such  as  we  are  familiar  with  in  the  case  of  the 
gall-bladder,  vermiform  appendix,  or  pelvis  of  the  kidney, 
when  they  become  cysts  by  retention.  The  first  efl"ect 
of  the  accumulating  fluid  upon  the  walls  of  the  tube  is 
to  stretch  them  ;  this  continual  pressure  induces  atrophy, 
the  pathological  sequence.  The  epithelium  and  mucous 
membrane  become  thin  and  atrophied  until  nothing 
but  a  thin-walled  transparent  cyst  remains,  with  delicate 
ridges,  representing  all  that  is  left  of  the  longitudinal 
plicae  of  the  tubal  mucous  membrane.  The  shape  of  a 
typical  hydrosalpinx  is  very  characteristic,  and  though 
not  invariable,,  is  fairly  constant;  it  resembles  a  legume 
with  somewhat  blunt  ends ;  the  ovary  always  occupies 
the  concave  border  of  the  legume,  and  the  bent  shape  of 
the  cyst  is  doubtless  due  to  the  traction  exercised  by  the 
tubo-ovarian  fimbria  or  ligament.  In  some  specimens 
the  situation  of  the  ostium  is  indicated  by  a  depression, 
from  which  a  series  of  folds  radiate,  as  in  Fig.  82,  remind- 
ing us  of  the  ridges  and  furrows  on  the  face  of  a  stump 
after  a  circular  amputation  through  the  thigh  or  arm.  In 
hydrosalpinx  the  tubes  rarely  attain  a  large  size.  This 
is  due  to  the  fact  that  as  the  tube  distends  the  mucous 
and  muscular  coats   atrophy.     The   largest   examples  of 


254 


Diseases  of  the  Fallopian  Tubes. 


hydrosalpinx  which  have  come  under  my  observation 
have  not  exceeded  i6  cm.  in  length,  with  a  diameter 
of  8  cm.  The  walls  of  these  cysts  were  so  thin  that 
the  fluid  probably  leaked  through  them '  in  the  same 
way  that  it  exudes   from  a  very  tense  ovarian  cyst  with 


Fig.  82. — Hydrosalpinx.     (Museum,  St.  Thomas's  Hospital.) 


attenuated  parietes,  and  is  gradually  absorbed  by  the 
peritoneum.  So  thin  are  the  walls  in  some  of  these 
hydrosalpinges,  that  even  when  very  carefully  manipulated 
during  operation,  they  rupture ;  it  is  very  probable  that 
these  dilated  tubes  may  cure  by  spontaneous  rupture,  the 
cyst  walls  afterwards  atrophying.  We  know  too  well  that 
such  an  event  sometimes  terminates  the  course  of  a 
pyosalpinx,  by  setting  up  fatal  peritonitis  ;  but  the  fluid 


Hydr  osal  pi  NX. 


255 


of  a  hydrosalpinx  would  be  tolerated  by  the  peritoneum 
in  the  same  way  that  it  tolerates  fluid  from  parovarian 
cysts  when  they  spontaneously  rupture.  My  reasons  for 
such  an  opinion  are  founded  on  the  following  evidence. 
I  have  had  many  opportunities  of  making  post-mortem 
examinations  of  the  bodies  of  prostitutes,  many  of  them 
having  led  a  life  of  vice  of  the  lowest  form.     In  most  of 


ATROPHIED    TUBE 
AND    OVARY 


Fisr.  8^.— Uterus  of  a  Harridan. 


them  double  hydro-  or  pyo-salpinx  existed.  In  three 
instances  in  which  I  examined  the  bodies  of  harridans 
I  found  one  or  both  Fallopian  tubes  represented  by 
an  impervious  cord,  and  the  ovaries  atrophied  and  un- 
recognisable. This  induces  me  to  believe  that  the 
frequency  of  tubal  disease  between  the  age  of  twenty 
and  thirty-five  years,  and  its  relative  rarity  after  the 
fortieth  year,  are  to  be  accounted  for  by  the  fact  that  if  the 
individual  survive  the  dangers  incidental  to  an  inflamed 
and  distended  tube  the  diseased  parts  atrophy.  The 
process    is    illustrated    by    the  specimen  represented  in 


256         Diseases  of  the  Fallopian  Tubes. 

Fig.  83.  It  is  the  uterus  and  appendages  of  a  harridan, 
aged  forty-four.  She  has  been  for  many  years  known  to 
the  poUce  as  a  notorious  prostitute.  The  uterus  was 
shrivelled,  the  right  ovary  and  tube  represented  by  thin 
impervious  bands  of  tissue.  The  left  tube  and  ovary 
are  represented  by  a  small  tubo- ovarian  abscess,  contain- 
ing a  small  quantity  of  colourless  fluid,  and,  in  the  recess 
formed  by  the  ovary,  some  caseous  material. 

Anatomical  evidence  indicates  that  when  the  infective 
qualities  of  the  pus  are  not  very  great,  a  pyosalpinx  may 
resemble  a  chronic  abscess,  and  give  rise  to  few  symp- 
toms. It  is  this  form  of  pyosalpinx  which  I  believe 
becomes  slowly  and  passively  dilated  with  fluid,  and  is 
transformed  into  a  hydrosalpinx.  My  reasons  for 
believing  that  a  hydrosalpinx  is  often  a  late  stage  of 
pyosalpinx  may  be  summarised  thus  : — 

1.  Hydrosalpinx  is  not  found  in  acute  cases. 

2.  In  many  chronic   cases  hydrosalpinx  is  found  on 

one  side   of  the   uterus,  and  a  progressive  pyo- 
salpinx on  the  other. 

3.  The  ampulla  of  a  tube  w^ill  sometimes  be  dilated 

into  a  hydrosalpinx,   and  the  isthmus  contains 
pus. 

4.  The  fluid  contained  in  a  hydrosalpinx  will  some- 

times be  colourless,  but  the  recesses  of  the  tube 
contain  caseous  material  and  cholesterine. 

5.  The  dilated  tube  in  hydrosalpinx  may,  as  in  pyo- 

salpinx, communicate  with  an  enlarged  ovarian 
follicle  to  form  a  tubo-ovarian  cyst. 
It  is  well  know^n  that  ovarian  cysts  are  prone  to 
undergo  axial  rotation,  and  in  some  instances  the  torsion 
may  be  so  severe  as  to  detach  the  cyst  from  its  con- 
nections. Axial  rotation  occurs  in  connection  with 
hydrosalpinx.  The  only  specmien  known  to  me  occurred 
in  the  practice  of  my    colleague,  Mr.  Henry  Morris.     I 


A  Rotated  Hydrosalpinx. 


257 


assisted  at  the  operation,  and  was  able  to  observe  the 
condition  thorouglily. 

The    cyst   was    a   typical   hydrosalpinx.       The    fluid 


TUBE. 


Fig.  84. — Hydrosalpinx  with  Twisted  Pedicle. 


contents  were  of  a  chocolate  colour.  The  portion  of  the 
tube  intervening  between  the  cyst  and  uterus  was  tightly 
twisted  three  times  and  a  half.  The  cyst  wall  was  adherent 
by  strong  adhesions  to  the  adjacent  parts  of  the  meso- 
metrium  and  pelvic  peritoneum,  and  it  doubtless  received 

R 


25§         Diseases  of  the  Fallopian  Tubes. 

its  nutrient  vessels  from  this  source,  for  its  relations  with 
the  blood-vessels  which  normally  supply  this  part  of  the 
tube  were  thoroughly  cut  off. 

Veit '"  briefly  mentions  a  case  of  torsion  of  a  hydro- 
salpinx in  which  haemorrhage  took  place  into  the  cyst, 
and  refers  to  my  specimen. 

When  ovarian  or  parovarian  cysts  undergo  axial 
rotation,  the  Fallopian  tube  is  necessarily  involved,  and 
in  cases  where  actual  separation  occurs  it  is  usually  the 
last  part  of  the  pedicle  to  be  detached. 

Iiiteriiiittiiig^  liydrof^alpinv. — It  has  been  stated 
on  clinical  evidence  that  the  fluid  in  a  hydrosalpinx  may 
escape  through  the  uterus,  the  blockade  of  the  uterine 
end  of  the  Fallopian  tube  being  raised.  Such  a  condi- 
tion is  termed  "  hydrops  tubae  profluens,"  the  escape 
of  fluid  taking  place  at  irregular  intervals.  Profuse  dis- 
charges of  pus  and  fluid  occur  in  connection  with  pyo- 
and  hydro-salpinx,  accompanied  by  a  diminution  in  the 
size  of  the  tumour,  and  are  easily  accounted  for  by 
the  formation  of  a  fistula  between  the  cyst  and  rectum,  or 
vagina.  There  is  no  trustworthy  pathological  evidence 
that  these  discharges  escape  into  the  uterus  by  way  of  the 
Fallopian  tubes. 

It  is  a  fact  of  some  interest  that  the  uterine  end  of 
the  Fallopian  tube  is  rarely  obliterated  in  salpingitis.  Of 
course,  the  tumidity  of  the  mucous  membrane  would  be 
sufficient  to  obstruct  the  passage  of  fluid  from  the  tube 
into  the  uterus. 

The  discharge  of  watery  fluid  from  the  uterus  in  gushes 
is  as  yet  without  an  explanation.  Skene  Keithf  has 
recorded  a  curious  example  which  occurred  in  an  un- 
married lady  thirty-six  years   of  age.     She  had  suffered 


*    Centmlhlatt fiir  Gyii.,  May  30th,  if 
t     Lancet,  May  2nd,  1891,  p.  985. 


Watery  Discharges  from  the  Uterus.    259 

from  the  age  of  twenty  years  from  discharges  of  fluid 
from  the  uterus,  which  were  so  profuse  as  to  render  it 
necessary  to  have  her  dresses  lined  with  waterproof  cloth, 
and  every  night  her  bed  had  to  be  made  up  as  for  a 
confinement.  The  discharge  was  thin,  had  a  heavy 
sickly  odour,  and  was  like  dirty  water. 

At  last,  to  remedy  the  condition,  the  ovaries  and 
tubes  were  removed,  but  nothing  was  found  to  account 
for  the  fluid. 

This  remarkable  case  makes  it  clear  that  gushes  of 
watery  fluid  from  the  uterus  must  not  by  themselves  be 
accepted  as  evidence  of  intermitting  hydrosalpinx. 
{See  also  page  284.)  I  pointed  out,  in  describing  ovarian 
hydrocele,  that  they  occasionally  intermit;  hydro-  and 
pyo-salpinx  may,  but  at  present  there  is  no  trustworthy 
evidence  based  on  anatomical  facts  that  the  fluid  contained 
in  such  cysts  escapes  through  the  tubes  into  the  uterus. 

It  is  a  fact  that  in  the  majority  of  distended  tubes, 
even  in  severe  cases  of  hydrosalpinx — the  uterine  end  of 
the  tube  is  obstructed  but  not  occluded. 

It  will  be  an  advantage  to  define  here,  briefly,  the 
terms  applied  to  the  various  pathological  conditions  of 
the  tube  : — 

1.  Pyosalpinx. — The  tube  is  distended  with  a  pus  or 

purulent  fluid. 

2.  Hydrosalpi7ix. — The  tube  is    distended  into  cyst 

which  contains  fluid :  in  some  specimens  clear 
and  albuminous,  in  others  of  a  chocolate  colour, 
and  in  old  specimens  flakes  of  cholesterine 
are  present, 

3.  lubo-ovarian   cyst. — The  ovary  is  replaced  by  a 

cyst  which  communicates  with  a  distended  tube. 
The  orifice  of  communication  is  an  adventitious 
opening,  and  does  not  represent  the  abdominal 
ostium  of  the  tube. 
R  2 


26o 


Diseases  of  the  Fallopian  Tubes. 


4.  Tiibo-ovarian  abscess. — Anatomically,  this  isatiibo- 
ovarian  cyst,  but  it  contains  pus,  and  the  cyst 
walls  are  very  thick.  The  orifice  of  communi- 
cation is  usually  small  and  barely  capable  of 
admitting  a  probe. 


Fig.  85. — Hydrosalpinx. 

5.  Ovarian  hydrocele. — The  tube  opens  by  its  ab- 
dominal ostium  into  a  cyst.  The  ostium  is 
recognised  in  rare  cases  -by  the  presence  of 
fimbriae  ;  more  frequently  by  longitudinal  ridges, 
which  emerge  from  the  walls  of  the  tube  and 
radiate  over  parts  of  the  cyst  wall  adjacent  to 
the  ostium.  The  ovary  is  either  incorporated 
in  the  cyst  wall  or  projects  into  the  cavity  of 
the  cyst. 
Often  it  is  exceedingly  difficult  to  decide  to  which 
group   a  given  specimen    belongs.     For  example,   if  in 


Hydro-peritone  um.  261 

Fig.  85  we  had  not  the  ovary  to  guide  us,  it  would  be 
difficult  to  decide  between  an  ovarian  hydrocele,  tubo- 
ovarian  cyst,  or  hydrosalpinx. 

ri'oqiieiicy  of  eliroiiie  sa1]>iiig;JtJs. — Distended 
and  purulent  tubes  are  very  frequently  found  during  J^ost 
inortein  examinations  of  individuals  in  whom  the  existence 
of  such  conditions  was  not  suspected  during  life.  It 
should  be  remarked  that  distended  tubes  are  very  rarely 
noted  unless  special  attention  is  directed  to  the  pelvic 
organs.  Two  sets  of  observations  bearing  on  this  question 
have  been  published.  The  first  was  the  communication 
to  the  Medical  Society  of  London  by  Dr.  Fowler,*  to 
which  reference  has  already  been  made.  He  found  in 
the  course  of  three  years  fifteen  examples  of  dilated  Fallo- 
pian tubes.  The  second  one  was  Dr.  Lewer'sf  paper, 
read  at  the  Obstetrical  Society,  London,  entitled.  On 
the  Frequency  of  Pathological  Conditions  of  the  Fallopian 
Tubes.  He  found  in  one  hundred  consecutive  dissec- 
tions of  the  pelvic  organs  in  females,  examined  in  the 
post  mortem  room  of  the  London  Hospital,  no  fewer  than 
seventeen  instances  of  dilated  Fallopian  tubes. 

Hydro-peritoiieuni  and  tubal  disease. —  It 
has  been  frequently  pointed  out  that  one  important  ad- 
vantage accruing  to  the  individual  from  occlusion  of  the 
abdominal  ostium  of  the  tube  in  septic  salpingitis  is  great 
diminution  in  the  risk  of  the  inflammation  extending  to  the 
peritoneum.  Apart  from  this,  even  mild  forms  of  tubal 
catarrh,  not  sufficient  to  give  rise  to  fatal  peritonitis,  nor 
even  severe  enough  to  seal  the  ostium,  may  cause  what  is 
called  hydro-peritoneum.  Mr.  Alban  Doranj  has  especially 
investigated  this    condition,    and  discussed  its  probable 

*  Medical  Society s  Proceedings,  vol.  vii.  p.  441  ;    1885. 
f   Trans.  Obstet.  Soc,  vol.  xix.  p.  199  ;   1887. 

J  "  Papillomaof  the  Fallopian  Tube  and  the  relation  of  Hydro-peri- 
toneum to  Tubal  Disease  ;"  Trans.  Obstet.  Soc,  1886,  vol.  xxviii. 


262  D/SEASES    OF    THE    FaLLOPIAN    TuBES. 

causation  in  an  admirable  paper  communicated  to  the 
Obstetrical  Society  of  London.  Hydro-peritoneum  he 
defines  as  a  collection  of  fluid  in  the  peritoneal  cavity 
which  cannot  be  referred  to  any  tangible  organic  disease. 
By  this  we  may  presume  he  means  that  the  accumulation 
is  not  due  to  the  ordinary  causes  of  ascites,  such  as  heart, 
liver,  or  kidney  disease.  The  definition  is  purely  clinical. 
Mr.  Doran  is  of  opinion  that  hydro-peritoneum  is  caused 
by  salpingitis  of  a  mild  type  with  an  unobstructed  tube. 
It  is  easy  to  understand  that  the  constant  irritation 
caused  by  inflammatory  products  dripping  from  the  tube 
into  the  peritoneal  cavity  would  induce  an  exudation  of 
fluid.  The  subject  is  one  of  some  importance,  and  de- 
mands more  attention  than  it  has  yet  received  at  the 
hands  of  those  who  conduct  ^ost  morte??i  examinations. 
Its  clinical  import  is  obvious  enough. 

Haeiiiatoisalpiiix. — Fallopian  tubes  are  frequently 
found  dilated,  as  in  hydrosalpinx,  but  filled  with  blood-clot. 
This  condition  is  hcemaiosalpinx — a  term  often  employed 
very  loosely.  Recent  observations  serve  to  show  that 
those  dilated  tubes  to  which  the  term  most  strictly  applies 
are  in  very  many  instances  gravid.  In  a  small  propor- 
tion of  the  specimens  it  is  exceedingly  diflicult  to  decide 
between  haemorrhage  into  a  previously  dilated  tube  and 
an  early  tubal  pregnancy.  My  observations  convince  me 
that  nearly  all  the  specimens  supposed  to  be  examples  of 
haematosalpinx  are  really  gravid  tubes,  from  the  fact  that 
in  all  the  cases  that  have  occurred  in  my  own  practice 
in  which  dilated  Fallopian  tubes  contained  blood-clot, 
a  careful  examination  of  the  parts  has  led  to  the  detec- 
tion of  an  embryo,  an  apoplectic  ovum,  or  chorionic  villi. 

In  similar  specimens  submitted  to  me  for  investiga- 
tion by  other  surgeons,  I  have,  in  nearly  all  cases,  suc- 
ceeded in  detecting  evidence  of  the  presence  of  an  im- 
pregnated ovum. 


Sterilftv  of  Strumpets.  263 

Many  museum  specimens,  supposed  to  be  examples  of 
haematosalpinx,  are  examples  of  very  early  tubal  preg- 
nancy. This  question  is  fully  discussed  in  the  section 
devoted  to  tubal  gestation.  The  term  hcEinatosalpmx 
should  be  exclusively  reserved  for  Fallopian  tubes  in  which 
the  abdominal  ostium  is  closed,  and  the  dilated  portions 
occupied  by  clot,  in  which  no  evidence  of  pregnancy, 
such  as  an  embryo,  apoplectic  ovum,  or  chorionic  villi,  is 
detected. 

It  must  be  remembered  that  neither  a  dilated  tube 
filled  with  chocolate-coloured  fluid  nor  an  undilated  tube 
containing  free  blood  is  a  haematosalpinx. 

As  far  as  my  observations  go,  a  dilated  Fallopian  tube 
containing  blood,  and  its  abdominal  ostium  unclosed,  will, 
in  nearly  all  cases,  be  found  gravid,  if  carefully  investi- 
gated. It  might  also  be  said  that  only  two  conditions 
lead  to  tubal  distension  with  an  unclosed  ostium  ;  these 
are  the  retention  of  an  impregnated  ovum  and  a  growth 
(adenoma)  within  the  tube. 

Even  in' gravid  tubes  in  which  the  pregnancy  has  pro- 
duced no  cataclysm  until  the  ostium  has  become  occluded, 
a  practised  eye  quickly  detects  the  difference  in  the  mode 
of  closure.  The  occlusion  of  the  ostium  in  salpingitis 
betrays  full  evidence  of  the  inflammatory  changes 
characteristic  of  the  disease. 

Sterility  of  struiiipets. — -Many  have  asked  the 
question,  "  How  is  it  that  strumpets  are  so  often  sterile  ?  " 
It  is  said  that  the  question  was  answered  many  years  ago 
by  Morgagni,  who  correctly  associated  it  with  occlusion  of 
the  tubes  as  a  consequence  of  inflammation  extending 
from  the  vagina.  I  have  looked  carefully  through  his 
letters,  but  have  failed  to  find  any  direct  statement  on 
this  matter.  The  sterility  of  strumpets  has  long  been 
known  ;  it  is  indicated  in  Hosea  iv.  10.  An  inquiry  into 
the  history  of  prostitutes  shows  that  many  of  them  have 


264  Z>JSEASF.S    OF    THF.    FaLLOPIAN    TuBES. 

fallen  from  virtue  and  given  birth  to  a  child  before  they 
began  a  life  of  systematic  prostitution.  It  is  equally 
certain  that  many  professed  strumpets  are  permanently 
sterile  because  inflammatory  affections,  such  as  vaginitis 
or  gonorrhoea,  are  soon  communicated  to  them,  and 
the  tubes  become  sealed. 

Very  early  in  my  pathological  investigations  I  used  to 
seize  opportunities  of  conducting /^j-/ w*?/'/^;;/  inspections 
in  a  parish  mortuary,  and  satisfied  myself  that  the  explana- 
tion of  the  sterility  of  strumpets  attributed  to  Morgagni 
is  the  correct  one. 


265 


CHAPTER  XXII. 

CATARRHAL    SALPINGITIS    IN    RELATION    TO    ADENOMA    OF 
THE    NECK    OF    THE    UTERUS. 

The  mucous  membrane  of  the  Fallopian  tubes  is  liable  to 
inflammation  of  a  mild  type,  conveniently  termed  catarrh,, 
which  causes  it  to  become  more  vascular  and  tumid,  and 
at  the  same  time  increases  the  amount  of  secretion 
furnished  by  its  glandular  recesses. 

The  tumidity  of  the  mucous  membrane  leads  to  tem 
porary  obstruction  of  its  lumen,  and  the  distension  of  the 
tube   consequent  on  the  retention  of  increased  secretion 
produces  a  considerable  amount  of  discomfort,  sometimes 
amounting  to  actual  pain. 

Catarrh  of  this  mild  type  is  apt  to  be  recurrent,  and 
is  often  confounded  with  oophoritis,  or  the  more  serious 
forms  of  salpingitis. 

In  a  fair  proportion  of  cases  it  is  associated  with,  if 
not  actually  secondary  to,  adenoma  of  the  neck  of  the 
uterus  :  the  condition  known  by  the  ridiculous  term  of 
erosion . 

The  mucous  membrane  of  the  neck  of  the  uterus  con- 
sists of  two  portions  :  one  lines  the  cervical  canal,  and  is 
continuous  with  the  mucous  membrane  of  the  uterine 
cavity  ;  the  other  covers  the  J^orfio  vaginalis,,  and  is  a  pro- 
longation of  the  mucous  lining  of  the  vagina.  The  two 
portions  meet  at  the  external  os.  The  mucous  membrane 
covering  the  vaginal  portion  of  the  cervix  "is  really 
cup  of  stratified  epithelium,  resembling  a  tailor's  thimble 
which  fits  on  the  lower  end  of  the  uterus  proper"  (Williams) 


266 


Diseases  of  the  Fallopian  TrsES. 


It  contains  a  few  simple  glandular  crypts.  The  cervical 
mucous  membrane  is  beset  with  many  racemose  glands, 
and  the  epithelium  is  of  the  columnar  variety. 

The  glands  of  the  cervical  mucous  membrane  fre- 
quently become  the  seat  of  adenoma,  which  invades  the 
mucous  membrane  of  the  vaginal  portion,  forming  a  soft 
velvety  areola  around  the  os.  This  tissue  resembles  in 
colour  a  ripe  strawberry,  and  is  thickly  dotted  with  minute 

spots  of  a  brighter 
pink.  The  surface  is 
usually  covered  with 
tenacious  mucus.  The 
OS  is  patulous,  and  the 
soft  spongy  material 
extends  up  the  cervical 
canal.  This  pink  tissue 
is  composed  of  glandu- 
lar acini,  lined  with 
large  and  very  regular 
columnar  epithelium. 

In  the  rarer  variety 
the  adenoma  projects 
in  the  form  of  a  polypus  from  the  os  ;  occasionally  two 
or  more  may  be  present.  They  are  soft  to  the  touch, 
and  dotted  over  with  minute  pores.  They  are  attached 
to  the  cervical  mucous  membrane,  near  the  os,  which 
is  markedly  patulous  when  these  pedunculated  ade- 
nomata are  present  (Fig.  86). 

Histologically,  they  are  composed  of  an  axis  of 
fibrous  and  muscle  tissue,  covered  by  mucous  membrane 
directly  continuous  with  that  hning  the  cervical  canal. 
As  long  as  these  pedunculated  tumours  remain  within 
the  canal  the  mucous  membrane  covering  them  possesses 
a  single  layer  of  columnar  epithelium  and  glands,  but 
when  the  tumour  increases  in  size  and  projects  into  the 


Fig.   86. 


Pedunculated  Adenomata  of  the 
Cervical  Canal. 


Tubal  Catarrh.  267 

vagina,  the  portion  which  is  no  longer  within  the  cervical 
canal  loses  its  glands  and  the  columnar  epithelium 
becomes  converted  into  the  stratified  variety  characteristic 
of  \\\^  portio  vaginalis.  As  these  outgrowths  rarely  attain 
a  large  size,  sections  may  be  easily  cut  through  their  whole 
length,  and  the  change  from  columnar  to  stratified  epi- 
thelium readily  studied. 

Another  important  fact,  and  one  frequently  over- 
looked, is  that  these  adenomatous  changes  are  not  by 
any  means  confined  to  the  neighbourhood  of  the  external 
OS,  but  in  many  cases  involve  the  mucous  membrane 
throughout  the  whole  length  of  the  cervical  canal. 

As  the  cervix  of  the  human  uterus  is  difficult  to 
obtain  in  a  condition  fit  for  preparing  trustworthy  sections 
for  the  microscope,  Mr.  Gordon  Brodie  kindly  assisted 
me  in  investigating  the  minute  structure  of  adenomata 
occurring  in  the  cervical  canal  of  monkeys. 

When  discussing  menstruation  it  w^as  pointed  out  that 
Macaque  monkeys,  when  living  in  confinement,  menstruate 
in  the  same  fashion  as  women.  Whilst  conducting  a 
series  of  observations  to  determine,  if  possible,  the 
menstrual  rhythm,  it  became  clear  that  these  monkeys, 
like  women,  are  liable  to  irregularities  in  the  duration, 
amount,  and  sequelae  of  this  extraordinary  phenomenon. 
Systematic  observations  carried  out  in  Macaques  showed 
that  they  are  liable  to  menorrhagia  and  leucorrhcea. 
As  occasions  offered,  monkeys  with  profuse  leucorrhcea 
were  killed,  and  the  genital  organs  examined.  The  naked- 
eye  characters  of  the  cervix  uteri  (Fig.  87)  were  identical 
with  those  exhibited  by  the  cervix  uteri  of  women  affected 
with  adenoma  (erosion).  The  mucous  membrane  of  the 
cervical  canal  was  tumid,  and  projected  beyond  the  os 
like  a  mass  of  granulations.  The  projecting  mass  is  of 
a  florid  red  colour  during  life,  but  is  quite  pale  after 
death.       This    spongy    tissue    extends    throughout    the 


268 


Diseases  of  the  FALLoriAN  Tubes. 


cervical  canal,  and  often  forms  rounded  prominences  in 
the  canal.  The  whole  of  this  spongy  mass  is  dotted  with 
circular  pores,  from  which  mucus  readily  exudes,  and  in 
large  quantities,  on  the  slightest  pressure. 

When  a  cervix  affected  with  adenoma  is  obtained 
quite  fresh  and  carefully  hardened,  very  instructive  sec- 
tions can  be  prepared  from  it,  if  they  are  cut  in  the 
long  axis  of  the  cervix,  and  in  such  a  way  as  to  include 

the  external  os,  the 
cervical  canal,  and 
portio  vaginalis. 

The  microsco- 
pical appearances 
are  shown  under  a 
low  power  in  Fig. 
88.  The  soft  ma- 
terial protruding 
from  the  os,  as  well 
as  polypoid  projec- 
tions in  the  canal, 
possess  the  glandu- 
lar type  of  structure 
so  characteristic  of  the  cervical  adenoma  of  women. 
The  acini,  or  recesses,  of  these  glandular  masses  are 
lined  with  a  single  layer  of  large  regular  columnar 
epithelium,  and  the  cavity  is  often  found  filled  wath 
mucus.  So  large  are  these  cells,  that  rows  of  them  are  seen 
in  some  of  the  sections  cut  at  right  angles  to  their  long 
axis,  producing  a  peculiar  honeycomb- like  appearance. 

These  recesses  develop  in  the  same  manner  as  glands  : 
that  is,  by  solid  down-growths  of  cells  derived  from  the 
surface  epithelium,  which  subsequently  acquire  a  central 
lumen.  This  process  may  be  studied  near  the  margin  of 
the  external  os,  where  the  cervical  glands  encroach  upon 
the  portio  vaginalis. 


Fig.   87. — Cervix   Uteri  of  a   Macaque    Monkej^ 
with  Adenoma  (erosion). 


Fig.  88.— Sagittal  Section  of  the  Cervix  Uteri  of  a  Macaque  Monkey  affected 
with  Adenoma.    Under  a  low  power. 


270         Diseases  of  the  Fallopian-  Tubes. 

The  study  of  this  condition  of  the  mucous  membrane 
in  the  cervical  canal  of  monkeys  is  very  instructive, 
because  it  serves  to  show  that  the  change  is  not  limited 
to  the  parts  immediately  adjacent  to  the  os,  but  involves 
in  severe  cases  the  entire  canal ;  it  also  indicates  that  the 
profuse  mucoid  or  leucorrhoaal  discharge  so  constantly 
attendant  on  this  condition  in  women,  as  well  as  in 
monkeyS;  is  altered  secretion  furnished  in  morbidly  large 
quantities  by  the  aberrant  glands. 

It  was  further  found  that  severe  forms  of  cervical 
adenoma  in  monkeys  were  associated  with  enlarged  and 
tumid  Fallopian  tubes,  and  in  a  few  instances  the  tubal 
mucous  membrane  presented  outgrowths  resembling 
papillomata. 

The  facts  obtained  from  a  study  of  adenoma  of  the 
uterine  cervix  in  monkeys  led  me  to  study  the  condition 
in  women,  especially  in  its  possible  relation  to  salpingitis. 

Many  cases  of  dysmenorrhoea  are  associated  with 
adenoma  of  the  cervix  in  women  beyond  any  suspicion 
of  gonorrhoea.  Several  such  cases  have  been  placed 
under  my  care  for  the  purpose  of  oophorectomy.  On 
examining  these  patients,  the  adenomatous  condition  of 
the  OS  is  recognised,  and  irregular  tender  swellings  can 
occasionally  be  felt  on  each  side  of  the  uterus.  When 
such  patients  are  kept  resting  in  bed,  these  tender 
swellings  will  subside,  and  often  re-appear  when  the 
patient  moves  about.  These  tender  pelvic  swellings  are 
in  many  instances  Fallopian  tubes  swollen  in  conse- 
quence of  catarrhal  conditions  of  the  mucous  membranes. 
As  the  inflammation  subsides,  the  swelling,  pain^  and 
tenderness  vanish. 

The  pain  experienced  by  these  patients  may  be 
explained  on  the  same  principles  as  that  experienced  in 
relapsing  appendicitis.  The  tumefaction  of  the  mucous 
membrane    temporarily    obstructs    the    communication 


Tubal  Catarrh.  271 

between  the  appendix  and  the  caecum  ;  this  leads  to 
distension  of  the  appendix,  in  consequence  of  the  accu- 
mulation of  mucus  furnished  by  the  glands,  and,  in  some 
cases,  inflammatory  products.  The  distension  of  an 
obstructed  appendix  causes  pain. 

As  soon  as  the  inflammation  subsides  sufficiently  to 
allow  the  blockade  to  be  raised,  tension  is  relieved  by 
the  escape  of  the  retained  fluid  into  the  Ccccum. 

This  matter  has  been  considered  somewhat  in  detail, 
because  localised  tender  swellings  on  each  side  of  the 
uterus  are  frequently  diagnosed  as  cases  of  oophoritis. 
Such  a  diagnosis  is  based  merely  on  clinical  observation, 
not  on  anatomical  evidence.  On  the  other  hand,  we 
have  specimens  which  absolutely  support  the  view  that 
distension  of  an  occluded  mucous  canal  is  invariably 
accompanied  by  intense  pain  and  tenderness. 

My  clinical  and  pathological  inquiries  have  led  me  to 
the  conclusion  that  many  cases  diagnosed  as  oophoritis 
are  really  instances  of  catarrhal  salpingitis,  and  in  a  cer- 
tain proportion  of  patients  are  associated  with,  and  in 
some  instances  secondary  to,  adenoma  of  the  mucous 
membrane  lining  the  cervical  canal. 


272 


CHAPTER   XXIII 

TUBERCULOSIS    AND    ACTINOMYCOSIS    OF    THE    OVARY 
AND    FALLOPIAN    TUBE. 

Our  knowledge  of  tuberculosis  of  the  ovary  and  Fal- 
lopian tube  is  not  very  satisfactory.  This  is  due  to  the 
fact  that  in  most  of  the  recorded  cases  the  diseased  parts 
have  not  been  subjected  to  careful  microscopic  examina- 
tion. It  has  been  shown  very  clearly  that  however 
suggestive  the  naked-eye  appearances  may  be,  the  lesions 
cannot  be  regarded  as  tubercular  unless  tubercle  bacilli 
are  found.  When  the  disease  in  the  ovary  or  tube  is 
part  of  a  general  infection,  the  detection  ot  tubercle 
bacilli  in  any  of  the  affected  organs  may  be  reasonably 
used  as  evidence  that  caseous  foci  in  the  ovary  or  tube 
are  also  tubercular. 

This  is  well  shown  in  Dr.  Percy  Kidd's  paper,  On 
the  Distribution  of  the  Tubei'de  Bacilli  in  the  Lesions  of 
Phthisis.*  In  this  inquiry  ninety  cases  were  investi- 
gated. Of  these,  twenty-three  were  females.  In  two  the 
Fallopian  tube  contained  caseous  material,  but  only  in 
one  case  were  bacilli  recognised.  The  report  of  this  case 
(No.  88)  runs  thus  : — 

^yjane  M.  :  Phthisis. — ^Fallopian  tube  distended  with 
firm  caseous  matter.  Bacilli  extremely  scanty  in  caseous 
contents." 

Silcockf  exhibited  to  the  Pathological  Society,  Lon- 
don, the  uterus,  tubes,  and  ovaries  of  a  child  five  years 

■•*  Medico-Chif.  Trans.,  vol  Ixviii.  p.  87. 

f   Trans.  Path.  Soi,,  London,  vol.  xxxvi.  p.  303. 


Tubercular  Salpingitis.  273 

of  age.  The  child  died  with  symptoms  of  tubercular 
meningitis  and  otonhcca.  At  ih.t  post niortein  examina- 
tion the  tympanum  was  filled  with  caseous  material ; 
miliary  tubercles  were  scattered  through  the  pia  mater  ot 
the  brain  and  spinal  cord,  and  similar  tubercles  occurred 
in  the  lungs. 

The  Fallopian  tubes  were  enormously  distended  with 
caseous  material,  their  walls  being  much  thinned.  The 
distension  was  greatest  at  the  fimbriated  end.  Both 
tubes  were  surrounded  by  old  adhesions.  The  cavity  of 
the  uterus  was  distended  with  caseous  material.  The 
peritoneum  exhibited  traces  of  peritonitis,  which  had 
subsided  some  little  time  previously.  Small  black 
nodules  the  size  of  millet-seeds,  or  smaller,  were  at- 
tached to  the  peritoneal  surface  of  the  intestines. 

Tubercle  bacilli  were  found  in  the  recent  tubercular 
foci  of  the  lung,  but  they  were  not  demonstrable  in  the 
caseous  contents  of  the  body  of  the  uterus  and  Fallopian 
tubes. 

This  is  a  valuable  case,  as  it  demonstrates  admirably 
the  nature  of  the  evidence  on  which  it  is  reasonable  to 
come  to  a  conclusion  that  the  lesions  in  the  uterus  and 
tubes  were  of  tubercular  origin.  I  remember  examining 
the  uterus  and  tubes  in  this  case  with  very  great  care  at 
the  time  the  specimen  was  shown  to  the  Society,  as  it 
was  the  first  unequivocal  case  of  tubercular  salpingitis 
that  had  come  under  my  notice. 

Percy  Kidd*  briefly  described  the  uterus  and  Fal- 
lopian tubes  from  a  girl  fourteen  years  of  age,  who  died 
of  pulmonary  phthisis  and  disseminated  tuberculosis. 
The  cavity  of  the  uterus  was  distended  with  yellowish 
gelatinous  fluid,  in  which  were  abundant  caseous  masses. 
The  left  Fallopian  tube  was  much  thickened,  and  its 

*   T?'ans.  Path.  Soc,  London,  vol.  xxxvii,  p.  357. 
S 


2  74         Diseases  of  the  Fallopian  1  ubes. 

walls  contained  caseous  nodules  and  patches.  Caseous 
fragments  from  the  uterine  wall  contained  tubercle  bacilli 
"scattered  about  in  very  small  groups." 

Ballantyne  and  Williams*  have  recorded  a  case  which 
occurred  in  an  unmarried  woman  twenty-eight  years  of 
age,  who  was  admitted  into  the  Edinburgh  Infirmary 
with  symptoms  of  tubercular  meningitis.  Menstruation 
had  begun  at  seventeen  years  of  age,  was  irregular,  and 
had  been  in  abeyance  during  the  six  years  preceding  her 
fatal  illness.  At  ih.Q  post  mortem  examination  tubercular 
disease  of  the  brain,  uterus,  and  Fallopian  tubes  was 
revealed.  The  lungs  and  peritoneum  were  healthy. 
Tubercle  bacilli  were  detected  in  the  lesions. 

Tutoerciilar  salpiiig-itis  has  wider  age  limits  than 
any  other  inflammatory  affection  of  the  tubes.  Undoubted 
cases  have  been  recorded  as  early  as  the  fifth  year,  and 
it  has  been  recorded  on  good  evidence  at  the  age  of 
forty.  The  greater  number  of  cases  occur  between  the 
fourteenth  and  twenty-fifth  years. 

The  naked-eye  characters  of  the  Fallopian  tube  when 
affected  with  tuberculosis  are  often  very  characteristic, 
but  sometimes  it  is  impossible  to  distinguish  between 
tubercular  tubes  and  an  ordinary  specimen  of  pyo- 
salpinx. 

In  many  instances  the  abdominal  ostium  is  occluded, 
and  the  lumen  of  the  tube  is  stuffed  tightly  with  caseous 
material.  The  tube  is  irregularly  distended  and  con- 
torted. On  turning  out  the  caseous  substance  the 
mucous  membrane  offers  the  usual  velvety  appearance 
so  frequently  presented  by  the  walls  of  a  chronic  abscess 
cavity.  In  other  specimens  the  tubercle  is  deposited  in 
the  walls  of  the  tubes. 

There  is  reason  to  believe  that  tuberculosis  of  the 

*  British  Med,  Journal,  Jan.  24th,  1891. 


Tubercular  Peritonitis.  275 

tubes  may  be  primary,  but  this  is  very  difficult  to 
demonstrate,  because  it  rapidly  extends  to  and  involves 
the  uterine  mucous  membrane.  When  the  abdominal 
end  remains  open,  the  tubercular  matter  leaks  into  the 
general  peritoneal  cavity  and  sets  up  tubercular  peritonitis. 

In  examining  a  body  with  disseminated  tubercle 
and  caseous  matter  in  the  Fallopian  tubes  it  is  difficult 
to  decide  whether  the  peritoneum  is  infected  as  part 
of  a  general  infection  or  from  the  escape  of  morbid 
material  from  the  tubes.  This  much,  however,  is  certain : 
that  we  do  sometimes  meet  with  tubercular  salpingitis 
with  completely  occluded  ostium  and  no  infection  of 
the  peritoneum,  but  it  is  unusual  to  find  tubercular 
peritonitis  and  no  tubercle  in  the  tube. 

Indeed,  the  facts  obtained  from  the  study  of  the 
morbid  anatomy  of  this  disease  indicate  very  clearly 
that  tubercular  salpingitis,  whether  primary  or  secondary, 
is  very  prone  to  spread  to  and  infect  the  peritoneum ; 
this  extension  is  due  to  the  escape  of  the  morbid 
material  through  the  abdominal  ostium  before  it  becomes 
completely  occluded.  This  circumstance  may  help  to 
explain  the  apparent  rarity  of  primary  tuberculosis  of 
the  tube.  Even  when  the  abdominal  ostium  is  occluded 
the  peritoneum  may  be  infected  by  perforation  of  the 
tube.  Dr.  Wheaton*  has  described  a  good  instance  of 
this.  The  patient,  aged  eighteen,  single,  had  a  swelling 
in  the  right  iliac  region,  which  was  opened,  and  from 
which  pus  continued  to  be  discharged  until  her  death, 
three  months  later,  from  exhaustion.  At  the  post  mortem 
examination  the  abscess  was  found  to  be  connected  Anth 
localised  suppurative  peritonitis,  due  to  the  perforation 
of  a  Fallopian  tube  by  tubercular  ulceration.  Tubercle 
bacilli  were  demonstrated  in  the  lesions. 

*    Trans.  Obstet.  Soc,  London,  vol.  xxxiii.  p.  29. 
S    2 


276         Diseases  of  the  Fallopian  Tubes. 

The  microscopical  characters  of  tubercular  salpingitis 
consist  of  inflammatory  thickening  of  the  serous  covering 
and  muscular  coat  of  the  tube.  The  enlargement  of 
the  muscular  coat  is  often  erroneously  referred  to  as 
hypertrophy ;  it  is  due  to  small  round-celled  infiltration. 
Here  and  there  small  nodules  are  seen  surrounded  by 
muscle  tissue  ;  such  nodules  present  the  characteristic 
histological  structure  of  tubercle,  and  in  favourable 
sections  suitably  prepared  tubercle  bacilli  may  be  de- 
tected. In  most  specimens  the  tubal  mucous  membrane 
is  destroyed  either  by  being  infiltrated  with  inflammatory 
products  or  by  ulceration. 

Tuberculosis  of  the  ovary  occurs  in  two  forms  :  either 
as  small  mihary  nodules  limited  to  its  capsule,  or  as 
caseous  masses  in  its  substance. 

The  first  variety  is  the  commoner,  and  in  probably  all 
cases  occurs  as  part  of  a  general  tuberculosis.  In  the 
majority  of  instances  it  is  associated  with  tubercle  of 
the  peritoneum,  but  may  occur  indei^endently  of  peritoneal 
infection. 

So  far  as  can  at  present  be  judged  from  the  records 
of  specimens  furnished  by  competent  observers,  the 
caseous  nodules  in  the  ovary  usually  form  part  of  a 
general  infection,  and  at  present  there  is  no  trustworthy 
evidence  that  the  ovary  is  affected  primarily  with 
tuberculosis.  In  many  of  the  specimens  of  ovarian 
tuberculosis  of  both  forms  the  Fallopian  tubes  were 
affected. 

An  ovarian  abscess  unassociated  with  salpingitis  is,  in 
nearly  all  cases,  tubercular  (Fig.  89). 

Records  of  ovarian  tuberculosis  require  careful  and 
critical  consideration  before  acceptance. 

Cystic  ovaries  in  which  the  albuminous  contents  have 
been  precipitated  by  immersion  in  alcohol  have  been 
recorded  as  examples  of  tuberculosis, 


Oi^ARiAN  Abscess. 


277 


An  admirable  account  of  some  specmiens  of  ovarian 
tuberculosis,  with  numerous  references,  has  been  pub.- 
lished  by  Dn  Griffith  * 

A  tubercular  abscess  of  the  ovary  sometimes  causes 
death  by  bursting  into  the  peritoneal  cavity. 


OVARY 


Fig.  89. — Tubercular  Abscess  of  the  Ovary-. 
The  mesosalpinx  is  infiltrated,  but  the  ostium  is  not  occluded. 

Diagnosis, — Little  has  been  done  in  the  direction  of 
formulating  rules  to  assist  in  the  clinical  recognition  of 
tubercular  disease  of  the  ovaries  and  tubes.  Yet  a  perusal 
of  careful  records  of  cases  indicates  several  facts  which 
seem  common  to  many  of  them. 


*    Trans.  Path.  Soc,  London,  vol.  xl.  p.  212. 


278         Diseases  of  the  Fallopian  Tubes. 

In  the  common  forms  of  salpingitis,  the  patients, 
whether  single  or  married,  not  infrequently  furnish  a 
history  of  gonorrhoea  or  septic  endometritis,  but  the 
majority  of  reported  cases  of  tubercular  salpingitis  have 
occurred  in  young  women  whose  life  in  this  respect  is 
often  above  suspicion.  In  girls  about  puberty  any  form 
of  salpingitis,  other  than  tubercular,  is  very  exceptional. 

The  signs  most  commonly  present  when  this  disease 
occurs  after  puberty  are  irregular  menstruation,  or,  in 
many  cases,  persistent  amenorrhcea,  sometimes  associated 
with  profuse  leucorrhcea  in  young  women  whose  life  and 
environment  are  of  such  character  as  to  put  gonorrhoea 
out  of  the  question.  If,  in  such  a  patient,  irregular 
swellings  are  found  on  each  side  of  the  uterus  occupying 
the  positions  of  the  ovaries  and  Fallopian  tubes,  the 
existence  of  tubercular  disease  of  these  organs  may  be 
suspected.  When,  in  addition  to  such  signs^  there  is 
evidence  of  tubercular  lesions  in  the  lungs,  the  suspicion 
as  to  the  nature  of  the  pelvic  lesions  should  be  more 
strongly  entertained. 

Tubercular  abscesses  of  the  ovary  sometimes  form 
fistulous  communication  with  the  rectum. 

Actiiioiiiyeosis  of  tlie  Fallopian  tiibo  has  been 
recorded  by  Zemann.*  The  patient  was  a  cook,  forty 
years  of  age.  At  the  post  mortem  examination  the  right 
tube  was  found  distended  with  purulent  material,  and 
actinomycotic  nodules  were  detected  in  the  walls.  The 
tube  was  enlarged  to  the  thickness  of  a  finger ;  its  walls 
were  hard,  and  adherent  to  the  surrounding  parts  and 
to  a  coil  of  the  ileum. 

Secondary  abscesses  existed  in  the  liver,  lungs,  and 
brain. 


*  "  Ueber  Aktinomykose  des  Bauchfelles,"  Case  iv.  ;     Medizinischt 
Jahrhikhcr,  Wien,  1883,  p.  477. 


Actinomycosis  of  the  Tube.  279 

Zemann  discusses  the  case  very  carefully ;  and  it  seems 
difficult  to  decide  whether  the  tube  became  secondarily 
affected  from  the  alimentary  canal  by  means  of  the 
adherent  loop  of  ileum,  or  was  the  primary  seat  of  the 
disease,  the  actinomyces  gaining  access  to  the  tube  by 
way  of  the  vagina.  The  evidence  indicates  that  the 
vagina  was  most  probably  the  channel  by  which  the  tube 
became  affected. 

Syphilitic  giimmata  have  been  reported  as  affecting 
the  tube.  Bouchard  and  Lepine"^  reported  a  case  in 
which  the  tubes  were  swollen  to  the  dimensions  of  a 
finger,  and  contained  three  gummata  the  size  of  nuts. 

*  Gaz.  Med.  de  Paris,  1866,  No.  41  ;  Boldt,  Xew  York  Med.  Record, 
1887,  vol.  xxxii.  p.  212. 


2»0 


CHAPTER  XXIV. 

NEOPLASMS  OF  THE  FALLOPIAN  TUBE. 

Neoplasms  of  the  Fallopian  tube  are  excessively  rare. 
They  are  adenoma^  niyoma^  and  cancer. 

Adenouia.- — When  describing  the  structure  of  the 
tubal  mucous  membrane,  the  question  of  the  glandular 
nature  of  its  recesses  was  fully  discussed.  If  the 
Fallopian  tube  contains  no  glands,  it  is  impossible  that 
it  can  give  rise  to  a  primary  adenoma ;  on  the  other 
hand,  if  the  mucous  membrane  be  glandular  the 
occasional  occurrence  of  an  adenoma  is  not  only  possible, 
but  probable. 

It  is  quite  certain  that  adenomata  of  an  interesting 
and  characteristic  type  occur  primarily  in  the  tube. 

In  1879  Doran*  exhibited  to  the  Pathological  Society, 
London,  a  Fallopian  tube  removed  by  Sir  Spencer  Wells 
from  a  maiden  lady  fifty  years  of  age.  On  laying  open 
the  tube  it  was  found  filled  with  a  cauliflower-like  ex- 
crescence, covered  with  mucoid  fluid  which  issued  from 
the  unclosed  abdominal  ostium.  The  general  appearance 
of  the  tumour  is  well  represented  in  Fig.  90.  The  ex- 
crescences grew  from  all  parts  of  the  mucous  membrane 
in  the  dilated  portion  of  the  tube.  Several  pedunculated 
cysts,  with  thin  walls,  rise  from  amidst  the  excrescences, 
and  contain  papillary  outgrowths.  The  free  surfaces  of 
the  outgrowths  are  covered  with  columnar  epithelium  ; 
some  of  the  cells  bear  cilia.     The  stroma  is  made  up  of 

*  Trans.  Path.  Soc,  London,  vol.  xxxi.  p.  174. 


Adenoma  of  the  Tube. 


281 


small  fusiform  connective  tissue"  cells  and  is  poorly 
supplied  with  blood-vessels.  The  microscopical  and 
naked-eye  characters  of  the  growth  induced  Doran  to 
describe  it  as  a  papilloma. 

Whilst  engaged  in  working  cut  the  morphology  of 
the  tubal  mucous  membrane,  I  took  the  opportunity  of 
re-examining  and  figuring  the  microscopical  characters  of 
this  rare  specimen,  and  had  no  difficulty  in   coming  to 


Fig.   90. — Adenoma  of  the  Fallopian  Tube.     (After   Doran.)    (]\Iu5euni, 
Royal  College  of  Surgeons.) 


the  conclusion  that  it  is  an  adenoma  developed  on  the 
type  of  the  glands  found  in  the  Fallopian  tube.  This 
relationship  is  well  brought  out  when  Fig.  91  is  compared 
with  Fig.  67,  showing  the  mucous  membrane  in  the  tube 
of  the  Macaque  monkey. 

Dr.  W.  Walter,  of  Manchester,  was  good  enough  to 
place  in  my  hands  for  examination  an  even  more  con- 
vincing specimen  of  Fallopian  adenoma  than  the  one 
just  considered. 

The  specimen  consisted  of  a  large  oophoritic  cyst, 
with  a  distended  Fallopian  tube.  On  examining  the 
tube  its  abdominal  ostium  was  found  largely  dilated,  and 


282         Diseases  of  the  Fallopian  Tubes. 

a  luxuriant  mass  of  vesicles,  like  a  bunch  of  grapes,  pro- 
truded from  it,  producing  an  appearance  not  unlike  a 
cornucopia  (Fig.  92). 


CAVITY 
OF  CVST 


Fig.   91. — Microscopical  Characters  of  a  Fallopian   Adenoma.     {Trans. 
Obstet.  Soc) 


On  laying  open  the  Fallopian  tube  the  vesicles  were 
found  to  involve  the  outer  third  of  the  tube  and  to  spring 
from  the  mucous  membrane.     At  first  it  seemed  as  though 


Adenoma  of  the  Tube. 


283 


one  had  to  deal  with  a  specimen  of  hydatid  mole  in  the 
Fallopian  tube. 

Sections  prepared  from  the  base  and  solid  parts  of 
the  tube,  when  examined  under  the  microscope,  exhibited 
the  structural  characters  of  an  adenoma.  The  solid  por- 
tion of  the  tumour  was  composed  of  delicate  connective 
tissue,  in  which  were   embedded  glandular  acini,  lined 


ADENOMA 


OSTIUM 


V  i//A   \ 


Fig.  92. — Adenoma  of  the  Fallopian  Tube.     (Dr.  Walter's  case.) 


with  a  single  layer  of  regular  columnar  epithelium.  In 
some  parts  of  the  tumour,  especially  near  the  surface, 
cystic  spaces  containing  sprouting  masses  of  intra-cystic 
growth  were  found.  The  specimen  differed  from  Doran's 
case  in  that  it  contained  a  far  larger  proportion  of 
stroma. 

An  interesting  feature  in  the  cHnical  history  of  these 
cases  is  the  presence  of  fluid  in  the  peritoneum — hydro- 
peritoneum.  In  the  case  described  by  Doran  the  fluid 
in  the  abdomen  was  removed  by  paracentesis  on  four 
occasions  between  March,  1-878,  and  the  removal  of  the 


284         Diseases  of  the  Fallopian  Tubes. 

tumour  in  April,  1879,  on  which  occasion  seventeen 
pints  of  fluid  were  evacuated.  In  addition,  the  patient 
suffered  from  fluid  effusions  in  the  right  pleura,  for  which 
she  was  twice  tapped.  After  the  removal  of  the  right 
tube,  with  the  tumour  contained  within  it,  the  effusions 
ceased,  and  the  patient  was  in  good  health  in  1886. 

In  Dr.  Walter's  patient  a  quantity  of  fluid  was 
present  in  the  peritoneal  cavity  at  the  time  of  the 
operation. 

The  relation  of  hydro-peritoneum  to  these  adenomata 
associated  with  patency  of  the  tubal  ostium  has  been 
made  the  subject  of  careful  and  suggestive  study  by 
Doran,  to  which  reference  has  already  been  made,  and, 
as  he  states  : — "  The  ostium  of  the  tube  remained  patent, 
and  hydro-peritoneum  persisted  until  the  diseased  tube 
was  removed.  The  evidence  that  the  secretion  escaped 
from  the  ostium  was  positive." 

An  additional  case  has  recently  been  published  by 
Dr.  Doleris,*  which  occurred  in  a  woman  twenty-eight 
years  of  age.  Both  ovaries  and  tubes  were  removed. 
The  right  tube  formed  a  cyst  of  the  size  of  a  small  nut- 
meg ;  masses  of  papillomatous  growths  sprang  from  the 
inner  wall  of  the  tube.  The  uterine  end  of  the  canal 
was  very  narrow ;  there  was  no  fluid  in  the  peritoneum. 
A  peculiar  clinical  feature  in  this  case  was  the  discharge 
of  large  quantities  of  sero-sanguineous  fluid  from  the 
vagina.  An  attempt  had  been  made  to  cure  this  by 
curetting  the  interior  of  the  uterus.  The  effect  of  this 
operation  was  to  produce  right-sided  parametritis.  The 
discharges  after  the  operation  became  continuous,  and 
the  fluid  pale  yellow,  and  of  a  syrupy  consistence,  which 
stiffened  linen  like  starch. 

This  is  an  extremely  interesting  clinical  observation, 

'^'  Bill,  de  la  Soc.  Obst.  et  Gyn.  Paris,  Jan.  1890. 


Adenoma  of  the  Tube. 


28s 


arid  should  be  studied  in  conjunction  with  Skene  Keith's 
remarkable  case,  referred  to  on  page  258. 

The  cyst  connected  with  the  right  Fallopian  tube,  in 
the  case  described  by  Doleris,  is  of  interest  in  connec- 
tion with  a  patient  under  my  care.  In  this  instance  I 
removed  from  a  very  stupid  Welshwoman,  aged  thirty- 
nine  years,  the  ovaries  and  tubes.  She  had  been  under 
the  care  of  several  medical  men  for  severe  pelvic  pain 


BAMD 


SEAT  OF  STRICTURE 


FRINGES 


Fig.  93. — Fallopian  Tube  strangulated  by  an  adhesion  between  the  Ovary 
and  Intestine. 
The  wall  of  the  tube  contjiiiis  a  cyst  the  size  of  a  walnut.  ' 

and  profuse  menorrhagia.  A  tender  and  painful  swelling 
of  some  size  existed  on  each  side  of  the  uterus. 

The  left  tube  was  strangulated  by  a  stout  adhesion 
connected  to  the  ovary  and  a  piece  of  intestine,  as  shown 
in  Fig.  93.  In  the  wall  of  the  tube  there  was  a  cyst,  the 
size  of  a  walnut,  filled  with  yellow  pultaceous  material. 
The  lumen  of  the  tube  at  the  seat  of  the  obstruction  was 
completely  occluded.     The  ostium  was  open. 

The  right  tube  was  enlarged  to  the  size  of  a  finger ; 
the  ostium  was  open,  the  walls  greatly  thickened,  and  its 
interior    stuffed  with  adenomatous    masses  in   structure 


2  86         Diseases  oe  the  Fallopian  Tubes. 

resembling  those  found  in  Doran's  specimen  (Fig.  90). 
There  was  no  hydro-peritoneum  or  watery  discharges 
from  the  vagina. 

There  is  good  reason  to  beUeve  that  adenomata  of 
the  Fallopian  are  not  infrequent.  Such  large  specimens 
as  those  described  by  Doran  and  Dr.  Walter  are 
doubtless  uncommon. 

Myoma. — Considering  the  frequency  of  myomata  in 
connection  with  the  uterus,  it  is  inexplicable  that  similar 
tumours  should  so  rarely  originate  in  the  Fallopian 
tubes. 

Reference  is  often  made  to  a  specimen  recorded  by 
Simpson,*  but  the  account  of  it  is  so  poor,  and  the 
drawing  intended  to  represent  it  so  crude,  that  it  is  of  no 
value. 

Spaeth  t  has  reported  the  clinical  history  of  a  myoma 
of  the  Fallopian  tube  removed  by  Prochownick .  from  a 
woman  thirty-nine  years  old.  The  tumour  was  some- 
what oval  in  shape,  5  J  by  4 J  cm.,  and  had  an 
average  thickness  of  4  cm.  There  was  no  trace  of  in- 
flammation, and  the  microscopical  characters  of  the 
mass  suggested  a  general  hypertrophy  of  the  connective 
and  muscle  tissues  of  the  tube. 

A  thorough  search  through  special  periodical  litera- 
ture of  the  past  ten  years  leads  me  to  emphasise  Virchow's 
statement  that  myomata  originating  in  the  muscular 
tissue  of  the  Fallopian  tube  are  very  rare,  and  are  almost 
always  so  small  as  not  to  merit  special  mention. 

I  have  satisfied  myself  that  when  there  is  general 
myomatous  enlargement  of  the  uterus,  the  muscle  tissue 
of  the  tubes  also  participates  in  the  change,  becoming 
thick  and  hard.      In  some  of  these  tubes  the  mucous 

*  Clinical  Lectures  on  the  Diseases  of  lVo>?ien,  p.  540. 
f  "  Ein  Fall,   von   Fibroid  der  Eileiters  ;  "  Zeitsch.  fUr  Geb,   zcnd 
Gyn.,  Bd.  xxi.  s.  363. 


Cancer  of  the  Tube.  287 

membrane  is  very  thin,  and  the  kmien  of  the  tube  reduced 
to  ahiiost  capillary  fineness. 

Cancer. — The  fact  that  the  Fallopian  tube  may  be 
the  seat  of  an  adenoma  leads  us  to  expect  that  it  would 
occasionally  be  affected  with  primary  cancer.  The  small 
amount  of  trustworthy  evidence  forthcoming  on  this  sub- 
ject is  sufficient  to  assure  us  that  this  dread  disease  is 
of  extreme  rarity  in  the  tubes. 

It  is  as  yet  impossible  to  write  a  general  account  of 
the  affection,  either  from  a  pathological  or  clinical  stand- 
point, but  there  can  be  little  doubt  that  the  widespread 
interest  now  manifested  in  the  diseases  of  the  Fallopian 
tubes  will  soon  lead  to  the  accumulation  of  evidence,  of  a 
trustworthy  character,  which  will  enable  us  to  come  to 
some  conclusion  as  to  its  existence,  probable  frequency, 
and  clinical  characters. 

In  the  meantime,  as  an  example  of  the  method  in 
which  such  cases  should  be  investigated,  critically 
analysed,  and  duly  recorded,  I  would  refer  to  Doran's"^ 
admirable  monograph  on  Frt?nary  Cancer  of  the  Fallopia7i 
Tube^  and  also  to  the  sequel  of  the  case  published  sub- 
sequently. It  contains  a  very  accurate  record  of  a 
remarkable  case.  The  histology  of  the  parts  is  illus- 
trated by  some  careful  drawings,  and  the  paper  contains 
references  and  criticisms  of  a  few  allied  cases  reported 
by  Continental  authors. 

Secondary  cancer  of  the  tube  has  never  been  recorded, 
but  cancer  of  the  body  of  the  uterus  extends  along  the 
mucous  membrane,  and  invades  the  tubes.  This  I  have 
seen  on  a  few  occasions. 

It  has  been  observed  by  several  who  have  had  oppor- 
tunities of  conducting  post  mortem  examinations  in 
advanced  cases  of   uterine  cancer  that  it  is  unusual  to 

*  Trans.  Path.  Soc,  Lo?idon,  vol.  xxxix,  p.  208  ;  and  vol.  xl.  p.  221. 


288         Diseases  of  the  Fallopian'  Tubes. 

find  the  tubes  invaded  when  the  cancer  originates  in  the 
cervix ;  but  it  is  common  to  find  the  tubes  in  the  con- 
dition of  hydro-  or  pyo-salpinx  under  such  conditions. 
When  the  disease  extends  upwards  into  the  cavity  of  the 
uterus,  it  will  occasionally  involve  the  tubal  mucous 
membrane,  but  extension  of  uterine  cancer  in  this  direc- 
tion is  the  exception  rather  than  the  rule. 


289 


CHAPTER    XXV. 

THE     DIAGNOSIS      OF      SALPINGITIS. 

The  leading  signs  of  acute  salpingitis  are  not  dependent 
upon  the  tube  itself,  but  become  most  strikingly  declared 
when  the  disease  involves  the  peritoneum  in  the  imme- 
diate vicinity  of  the  ostium  of  the  tube. 

In  acute  gonorrhceal  salpingitis  the  patient  complains 
of  a  vaginal  discharge,  for  which  she  may  be  already 
under  treatment,  and  adds  that  she  has  been  suddenly 
attacked  by  severe  pain  in  one  or  both  flanks.  On 
examining  the  abdomen  it  will  be  found  that  even  light 
pressure  evokes  pain,  and  on  vaginal  examination  the 
ovaries  will  be  found  swollen  and  tender.  With  rest  and 
appropriate  treatment  these  symptoms  subside  or  become 
chronic,  but  in  a  certain  proportion  of  cases  the  local 
tenderness  and  pain  extend  over  the  belly,  accompanied 
by  distension,  high  temperature,  vomiting,  and  the  usual 
signs  of  general  peritonitis,  which  sometimes  kills  the 
patient.  Similar  conditions  occur  in  connection  with 
acute  salpingitis,  secondary  to  septic  endometritis^  follow- 
ing abortion,  dehvery,  and  irritation  caused  by  intra- 
uterine injections  and  instrumentation  of  the  uterus. 
The  discharges  from  the  uterus  may  be  at  first  clean, 
then  they  become  foul,  and  the  patient's  temperature 
slowly  rises  to  100°  Fahr.  Suddenly  the  patient  is 
seized  with  a  rigor,  the  temperature  rises  to  103'^  or 
104'',  the  belly  swells  and  becomes  tender,  there  are 
vomiting  and  all  the  signs  of  general  infective  peri- 
tonitis.   This  may  kill  the  patient  in  a  few  days,  and  the 

T 


290         Diseases  of  the  Fallopian  Tubes. 

practitioner  classifies  the  disease  under  the  vague  and 
meaningless  phrase,  puerperal  fever.  The  sudden 
accession  of  pain  and  fever  indicates  the  extension  of  in- 
flammation from  the  mucous  membrane  of  the  tube 
to  the  peritoneum^  but  more  frequently  infection  of 
the  great  serous  cavity  by  the  escape  of  putrid  material 
through  the  as  yet  unclosed  ostium  of  the  tube.  As  a 
rule,  sloiv  accession  of  symptoms  indicates  gradual  ex- 
tension from  mucous  and  muscular  to  serous  tissue. 
Sudden  onset  of  the  ominous  signs  usually  means  actual 
leakage  from  the  tube  into  the  peritoneal  cavity.  This 
may  be  interpreted  clinically :  slow  extension  leads  to  chronic 
changes ;  leakage^  as  a  rule^  leads  to  general  peritoneal  in- 
fectiofi,  and^  not  infrequently^  death.  In  some  cases  acute 
infection  of  the  peritoneum  is  indicated  by  severe  collapse. 
Cases  of  this  nature  are  rarely  seen  by  the  surgeon.  In 
1890  I  communicated  to  the  Obstetrical  Society  a  de- 
scription of  a  case  instructive  in  the  direction  of  showing 
the  suddenness  with  which  the  symptoms  indicative  of 
infection  of  the  peritoneum  are  announced. 

A  woman  forty-three  years  of  age  came  under  my  care 
for  the  removal  of  a  large  gangrenous  myoma,  which  had 
become  in  part  extruded  through  the  os  uteri  into  the 
vagina ;  a  portion  of  it  projected  beyond  the  genital 
orifice.  The  putrid  mass  was  removed  by  means  of  an 
ecraseur,  and  the  uterine  cavity  freely  irrigated  with  sub- 
limate solution  (i  in  2,000) ;  the  mucous  membrane  was 
ascertained  to  be  gangrenous.  For  a  few  days  after  the 
operation  the  patient  promised  to  do  well ;  there  was  no 
pain  or  tenderness  ;  the  temperature  rose  to  loi^  in  the 
evening,  but  in  the  morning  fell  to  99°.  This  rise  was 
due  to  the  condition  of  the  uterus.  On  the  evening  of 
the  third  day  after  the  operation  the  patient  complained 
of  sudden  acute  abdominal  pain,  followed  by  symptoms 
of  shock,  and  she  seemed  about  to  die  :  the  temperature 


Salpingitis  axd  Peritonitis.  291 

fell  from  101°  to  97°  Fahr.  In  twelve  hours  the  collapse 
passed  off,  severe  peritonitis  followed,  and  the  patient 
died  two  days  later.  At  the  post  mortem  examination 
septic  fluid  and  sloughs  of  the  tubal  mucous  membrane 
were  found  projecting  from  the  unclosed  ostia  of  the 
tubes.     The  parts  are  represented  in  Fig.  70. 

The  connection  between  salpingitis  and  puerperal 
peritonitis  has  been  pointed  out  by  many  writers.  In 
1862  Dr.  Robert  Barnes"^  placed  on  record  "a  case  of 
peritonitis  caused  by  the  escape  of  pus,  or  putrilage,  from 
the  Fallopian  tube  into  the  abdominal  cavity,  following 
an  abortion  artificially  induced."  The  patient  was  thirty- 
four  years  of  age,  and  she  died  six  days  after  delivery, 
from  peritonitis,  impost  mortem  examination  was  made 
on  a  coroner's  warrant.  Pus  w^as  detected  in  the  uterus 
and  Fallopian  tube.  In  the  left  tube  "  pus  was  distinctly 
traceable  into  the  peritoneal  cavity." 

Dr.  Barnes  in  reporting  this  case  refers  to  several 
writers  who  have  observed  and  recorded  instances  of  a 
similar  mode  of  infection. 

One  of  the  cases  is  briefly  but  graphically  described. 
It  is  related  by  Vocke  : — "  On  the  ninth  day  after  labour 
a  young  woman — her  progress  to  that  time  appearing 
satisfactory — was  suddenly  seized  with  acute  pain  in  the 
seat  of  the  left  ovary,  and  died  in  forty-six  hours.  In  the 
abdomen  were  found  several  quarts  of  sero-purulent  ex- 
udation. The  peritonitic  signs  were  all  most  intense 
around  the  opening  of  the  left  tube.  This  tube  gave 
forth  little  streams  of  pus  when  it  w^as  squeezed  towards 
its  end." 

Other  observers  w^ho  have  made  similar  observations 
mentioned  by  Dr.  Barnes  are  Ed.  Martin,  of  Berlin, 
Forster,  and  Dr.  F.  Howitz.      Martin  reports  that  "  when 

*  Trans.  Obstet.  Soc,  London,  vol.  iii.  p.  419. 
T    2 


292         Diseases  of  the  Fallopian  Tubes. 

the  escape  of  pus  takes  place  sudden  acute  pain  follows, 
then  fever.  The  quick-ensuing  tympanitis  may  obscure 
the  signs  of  peritonitis." 

Delbet*  mentions  that  Siredey^  in  a  thesis  published 
in  Paris,  i860,  states  that  in  twenty-nine  autopsies  made 
upon  women  who  had  died  from  puerperal  affections  he 
found  in  twenty-two  the  tubes  dilated,  full  of  pus,  and 
the  ovaries  purulent. 

In  Great  Britain  very  little  attention  has  been  de- 
voted to  this  subject.  The  most  significant  observation 
on  this  matter  is  that  made  by  Chapman  Grigg,t  to  the 
effect  that  in  five  patients  who  died  at  Queen  Charlotte's 
Lying-in  Hospital  with  symptoms  oi  puerperal  fever,  out 
of  a  total  of  548  deliveries,  extending  over  a  period  of 
nine  months,  four  were  due  to  antecedent  disease  of  the 
ovaries  or  tubes.  The  conditions  found  in  each  case, 
post  uwrtein,  were  : — 

1.  Multilocular  cyst  of  right  ovary,  containing  pus. 

2.  Abscess  of  left  ovary  and  pyosalpinx. 

3.  Ovarian  cyst  (ruptured)  and  old  pelvic  cellulitis. 

4.  Chronic  inflammation  of  the  broad  ligament  and 

Fallopian  tubes,  causing  pressure  on  the  ureters 
(eclampsia). 

In  the  four  cases  the  patients  were  young  women, 
their  ages  being  twenty-one,  twenty-two,  twenty-three,  and 
nineteen  years  respectively.  Such  a  record  is  very  sig- 
nificant, and  needs  no  comment. 

Cliroiiic  sa.lpiiig'atis  is  a  very  common  disease, 
and  one  that  not  infrequently  imperils  life;  even  in  cases 
where  life  is  not  endangered  the  pain  and  inconvenience 
the  patients  suffer  are  often  such  as  to  render  their  exis- 
tence miserable. 


*  Des  Supptii'atio?is  Pelvieniics  dicz  la  Fcmmc  ;  Paris,  1891. 
f  Journal  of  ihe  British  Gyncecological  Sociefy,  vol.  ii.  p.  264. 


The  Signs  of  Salpingitis.  293 

Unfortunately,  the  effects  of  chronic  salpingitis  are 
imitated  by  several  morbid  conditions,  so  that  positive 
diagnosis  is  very  difficult.  A  careful  inquiry  into  the 
history  of  the  case  will  bring  to  light  the  fact  that  the 
patient  has  had  gonorrhoea,  but  much  more  frequently 
we  shall  obtain  evidence  that  some  years  previously  the 
patient  had  a  difficult  labour,  or  an  abortion  complicated 
with  septic  troubles,  and  since  then  has  remained  sterile. 
She  will  further  add  that  after  the  illness  her  menstrual 
periods  began  to  be  profuse,  and  of  longer  duration.  In 
some,  menstruation  is  too  frequent.  In  most,  defsecation 
is  painful,  and  sexual  congress  so  attended  with  pain 
that  they  avoid  it.  In  a  certain  proportion  of  cases  there 
is  a  purulent  vaginal  discharge. 

It  has  been  stated  by  one  or  two  writers  that  instead 
of  menorrhagia  there  is  a7nenorrh(Ea.  My  experience  is 
that  amenorrhoea  accomp?aiying  other  signs  of  salpingitis 
usually  indicates  that  the  tubal  mischief  is  tubercular. 

On  examining  the  abdomen,  an  irregular  tender 
swelling  may  be  sometimes  detected  in  one  or  both 
flanks  ;  more  frequently  there  is  an  indefinite  swelling, 
and  in  some,  on  palpation,  a  sense  of  resistance  can  be 
made  out,  but  in  very  many  cases  no  sweUing  can  be 
detected  by  palpation  of  the  abdomen. 

On  internal  examination  there  will  be  found  lying  on 
each  side  of,  or  behind,  the  uterus  an  elongated  swelling, 
which  usually  gives  rise  to  great  pain  when  pressed  by 
the  examining  finger.  Not  infrequently  the  uterus  is 
acutely  retroflexed,  and  then  the  uterine  fundus,  with  the 
enlarged  tubes  and  ovaries,  forms  a  rounded  ridge  running 
transversely  across  the  pelvic  floor. 

As  a  rule,  a  moderately  distended  tube  can  only  be 
felt  through  the  vagina,  or  by  the  bi-manual  method 
of  examination  :  that  is,  when  the  index  finger  is  in 
the  vagina,  and  the   opposite   hand  pressed    upon   the 


294         Diseases  of  the  Fallopian  Tubes. 

abdominal  wall,  the  fingers  of  each  hand  will  compress 
between  them  the  enlarged  body,  be  it  tube  or 
ovary. 

Frequently  an  enlarged  or  distended  tube  is  more 
readily  felt  through  the  rectum  than  through  the  vagina. 
As  collections  of  faeces  in  the  rectum  may  not  only  lead 
to  false  notions  as  to  the  existence  of  an  inflamed  tube, 
but  render  difficult,  as  well  as  disagreeable,  a  proper 
rectal  examination,  it  is  always  advisable  to  take  pre- 
cautions to  have  the  rectum  thoroughly  emptied  by 
means  of  an  enema  some  hours  before  the  examina- 
tion. 

Many  conditions  simulate  disease  of  the  Fallopian 
tubes. 

Small  tiimoiiris  of  tlie  ovary. — When  speaking 
of  cystic  disease  of  the  ovary  we  are  so  apt  to  associate 
the  condition,  especially  when  discussing  the  question 
from  the  surgical  side,  with  large  tumours  rising  above  the 
pelvic  brim,  that  it  is  often  forgotten  that  small  cysts  of 
the  ovary  not  infrequently  produce  more  discomfort  and 
actual  pain  than  larger  tumours  of  this  organ.  The 
ovary,  like  the  testis,  is  acutely  sensitive  to  pressure,  and 
when  it  is  slightly  enlarged  and  increased  in  weight  it 
drags  upon  the  broad  "ligament,  so  that  instead  of  hanging 
suspended  in  the  pelvis  it  lies  on  the  floor  of  the  recto- 
vaginal fossa.  The  ovary  under  such  conditions  is  apt 
to  give  rise  to  pain  during  defaecation,  especially 
if  it  is  the  left  one  that  is  affected.  In  these  cases  pain 
during  sexual  congress  is  a  prominent  symptom,  and  fre- 
quently the  one  for  which  the  patient  most  urgently 
seeks  relief.  On  examining  the  patient  a  rounded 
movable  body  about  the  size  of  a  walnut  is  felt  behind 
the  uterus  ;  when  pressed  by  the  examining  finger,  pain 
is  evoked.  When  the  ovary  is  movable  it  can .  rarely  be 
mistaken  for  a  distended  tube,  but  when  bound  down  by 


Conditions  siMULAriNc  Salp/ng/tis.        295 

adhesions  such  ovaries  are  frequently  diagnosed  as  dis- 
tended tubes. 

Another  mode  in  which  small  cysts  cause  pain  is  when 
they  become  impacted  in  the  pelvis.  Such  a  specimen 
is  shown  in  Fig.  13.  This  ovary  was  removed  by  Mr. 
H.  W.  P'reeman  from  a  young  married  lady,  who  com- 
plained of  almost  constant  pelvic  pain  and  leucorrhoeal 
discharge.  On  examining  her  through  the  vagina,  an 
indistinct  swelling  could  be  made  out  on  the  left  side  of 
the  uterus.  The  elongated  rounded  border  presented  by 
the  cyst  when  impacted  between  the  uterus  and  pelvic 
brim  caused  it  to  resemble  a  distended  tube.  This  view 
of  the  case  was  further  suggested  by  the  existence  of  a 
profuse  vaginal  discharge  and  intensification  of  pain  at 
the  menstrual  periods.  The  evening  preceding  the 
operation  the  patient  complained  of  intense  pain  in  the 
pelvis,  and  began  to  menstruate.  As  the  ovary  was 
drawn  up  through  the  wound,  a  follicle  which  could  only 
have  been  ruptured  a  few  hours  was  detected  on  the 
surface. 

The  ovarian  cysts  that  cause  most  pain  are  small 
dermoids,  equal  to,  or  scarcely  larger  than,  a  Tangerine 
orange.  These  become  firmly  fixed  by  adhesions  to  the 
peritoneum  in  the  recto-vaginal  fossa,  and  cause  intense 
suffering.  They  are  usually  diagnosed  as  distended 
tubes. 

It  is  very  difficult,  and  often  impossible,  to  differ- 
entiate before  operation  between  a  small  cyst  impacted 
in  the  pelvis  and  a  distended  tube,  because  the  com- 
pression alters  the  shape  of  the  cyst.  For  instance,  the 
parovarian  cyst  sketched  in  Fig.  43  was  so  wedged  in 
between  the  uterus  and  the  pelvis  that  it  resembled  the 
tubular  sausage-like  feel  of  a  moderately  distended  Fal- 
lopian tube  ;  pressure  by  the  examining  finger  caused 
intense  pain.     So  tightly  was  the  cyst  impacted  that  ^ 


296         Diseases  of  the  Fallopian  Tubes. 

required  some  force  to  dislodge  it.  There  were  no 
adhesions  and  no  signs  of  inflammation  ;  it  was  therefore 
reasonable  to  attribute  the  pain  to  pressure  resulting 
from  impaction. 

This  specimen  may  with  advantage  be  compared  with 
the  cyst  sketched  in  Fig.  41.  Such  cysts  cause  much 
pain  ;  they  are  freely  movable,  and  are  usually  mistaken 
for  enlarged  ovaries.  Patients  with  cysts  of  this  nature 
describe  the  pain  as  of  a  dragging  character,  probably 
due  to  the  tension  the  cysts  exert  upon  the  tubes,  for  in 
all  the  specimens  I  have  examined  in  which  the  cyst  was 
situated  in  this  peculiar  relation  to  the  tubo-ovarian 
ligament  the  tubes  were  greatly  elongated.  It  is  possible 
that  the  strain  exerted  upon  the  tubo-ovarian  ligament 
produces  painful  sensations. 

Other  conditions  of  the  ovary  likely  to  lead  to  error 
in  the  differential  diagnosis  of  ovarian  enlargement  and 
tubal  distension  are  haemorrhages  into  its  follicles,  or  into 
the  stroma — the  so-called  "apoplexy  of  the  ovary" — - 
and  ovarian  growths,  such  as  myoma  or  sarcoma,  in  their 
early  stages. 

The  clinical  signs  of  ovarian  disease  are  very  similar 
to  those  of  testicular  disease,  in  so  far  as  pain  is  con- 
cerned. Haemorrhage  into  the  substance  of  the  testis, 
or  inflammation,  causes  intense  pain ;  whilst  a  large 
hydrocele  produces  no  pain,  and  a  sarcoma,  in  most 
cases,  gives  rise  to  a  feeling  of  discomfort,  due  to  the 
tension  it  exerts  upon  the  spermatic  cord. 

In  a  general  way  it  may  be  stated  that  it  is  im- 
possible to  accurately  diagnose  between  the  various 
forms  of  tubal  distension  and  the  following  forms  of 
ovarian  disease  : — 

1.  Tubercular  abscess  of  ovary. 

2.  Apoplexy  of  the  ovary. 

3.  Small  oophoritic  or  paroophoritic  cysts. 


Conditions  simulating  Salpingitis.         297 

4.  Small  parovarian  cysts. 

5.  Solid  ovarian  tumours  in  their  early  stages. 

6.  Small  ovarian  dermoids. 

7.  Early  tubal  pregnancy. 

A  few  suggestions  relative  to  the  diagnosis  of  tuber- 
cular salpingitis  and  oophoritis  are  given  at  the  end  of 
chapter  xxiii. 

Retroflexion  of  the  uterus  has  been  mistaken  for 
tubal  disease.  I  have  known  the  abdomen  to  be  opened 
for  the  purpose  of  removing  tubes  supposed  to  be  diseased 
when  only  a  retroflexed  fundus  was  found.  It  seems 
difficult  to  understand  how  such  an  error  could  arise. 
It  is  quite  as  serious  to  commit  the  converse  error,  and 
mistake  an  inflamed  or  distended  tube  for  a  simple 
flexion  of  the  uterus,  and  proceed  to  treat  the  case  with 
a  pessary,  or  attempt  to  straighten  it  with  a  uterine  sound. 
I  remember  well  seeing  an  enterprising  obstetric  physician 
introduce  a  sound  to  "  straighten  a  retroflexed  uterus  " 
in  a  woman  twenty-four  years  of  age.  The  manoeuvre 
caused  great  pain  and  shock.  In  a  few  hours  general 
peritonitis  ensued,  and  death  occurred  two  days  after- 
wards. At  the  post  mortem  examination  a  ruptured  pyo- 
salpinx  was  found.  It  has  been  already  mentioned  that 
a  flexed  uterus  is  sometimes  associated  with  enlarged  and 
adherent  tubes. 

It  is  in  such  cases  that  the  so-called  minor  gynaeco- 
logical operations  are  often  productive  of  m.ischievous, 
and  even  fatal,  results. 

To  dilate  and  curette  the  interior  of  the  uterus  in  a 
woman  whose  tubes  are  distended  with  pus  will,  in  many 
instances,  endanger  life. 

Bladder  troubles  in  connection  with  pelvic  tumours 
and  inflammatory  swellings  occasionally  arise.  Apart 
from  the  diseases  of  the  bladder  itself,  interference  with 
micturition  may  occur  in  pelvic  cellulitis  (especially  when 


298         Diseases  of  the  Fallopian  Tubes. 

it  affects  the  tissues  anterior  to  the  uterus),  impacted 
icterine  7fiyomafa,  iinpacled  ovaria?i  de?i?ioids,  in  retro- 
version of  the  gravid  uterus,  and  in  anterior  serous 
peri??ietritis. 

Retroversion  of  tlie  gravid  litems  means  that 
the  body  of  the  uterus  is  lodged  in  the  hollow  of  the 
sacrum,  and  is  prevented  from  rising  on  account  of  the  pro- 
montory of  the  sacrum.  As  the  uterus  enlarges  the  cervix 
is  raised,  compresses  the  urethra,  and  causes  retention, 
often  accompanied  by  incontinence  {ischuria  paradoxica). 
The  clinical  signs  of  a  gravid  uterus  in  this  condition 
are  very  decided.  First,  there  is  the  presence  of  an  oval 
hypogastric  tumour,  the  over-full  bladder,  a  history  of 
pregnancy  between  the  third  and  fourth  month ;  and  on 
examination,  a  rounded  elastic  swelling  (the  body  of  the 
uterus  occupying  the  hollow  of  the  sacrum)  will  be  felt, 
whilst  the  cervix  lies  behind  the  pubes,  and  sometimes 
so  high  that  the  finger  can  scarcely  reach  it.  On  passing 
a  catheter  and  emptying  the  bladder  the  hypogastric 
tumour  will  disappear.  On  examining  the  abdomen  bi- 
manually  the  uterus  will  not  be  found  in  the  abdomen. 
These  facts  serve  to  distinguish  an  incarcerated  uterus 
from  uterine  myomata,  tubal  pregnancy,  or  ovarian 
tumour,  for  in  all  these  conditions,  when  the  cervix  lies 
behind  the  symphysis,  the  fundus  of  the  uterus  can  be 
felt  through  the  anterior  abdominal  wall.  The  diagnosis 
is  usually  verified  by  rectifying  the  position  of  the  uterus. 
After  emptying  the  bladder,  upward  pressure  on  the 
uterus  through  the  vagina  will  cause  it  to  ascend.  Some- 
times it  will  be  necessary  to  administer  an  ansesthetic. 
Hurry*  has  published  a  valuable  series  of  cases  illus- 
trating the  signs  of  retroversion  of  the  gravid  uterus. 
Dr.  Godsonf  communicated  an   interesting  paper  to  the 

*  St.  Barth.  Hosp.  Reports,  vol.  xix.  p.  297. 
t  Proc.  Med.  Soc,  LondoJi,  vol.  vii.  p.  385. 


Conditions  simulating  Salpingitis.        299 

Medical  Society,  London,  1884,  giving  a  brief  account  of 
the  early  literature  of  this  condition. 

Tactile  judgment  is  a  very  important  factor  in  the 
diagnosis  of  pelvic  swellings.  To  estimate  the  size,  con- 
sistence, mobility,  or  fixity,  etc.,  of  a  tumour  lying  in 
close  relation  with  the  uterus  requires  experience.  At 
consultations  the  most  varied  opinions  are  expressed :  a 
pelvic  swelling,  which  one  will  estimate  as  equal  in  size 
to  a  walnut,  to  another  feels  as  large  as  an  egg.  This 
difference  in  the  delicacy  of  touch  often  leads  to 
erroneous  opinions  at  consultations,  and  is  productive 
of  much  misunderstanding. 

In  a  general  way  it  may  be  stated  that  2uhe?i  a 
Fallopian  tube  is  so  distended  as  to  render  it  capable  of 
being  felt  above  the  pelvic  brim.,  it  is  liable  to  be^  and  often 
is,  mistaken  for  an  ovarian  cyst. 

On  the  other  hand.,  when  ovarian  and  parovarian  cysts 
are  not  large  enough  to  be  felt  above  the  pelvic  bf'im,  they 
are  usually  diagnosed  as  pelvic  cellulitis.,  or  distended  tubes. 

In  addition  to  the  ovarian  conditions  mentioned  on 
page  296  with  which  tubal  disease  is  frequently  con- 
founded, and  from  which  it  is  scarcely  possible  to  dis- 
tinguish them  clinically,  the  following  hst  indicates  other 
sources  of  error  : — 

8.  Retroflexion  of  the  uterus. 

9.  Pelvic  cellulitis  (parametritis). 

10.  Faecal  accumulation  in  the  rectum. 

11.  Kidney  in  the  hollow  of  the  sacrum. 

12.  Small  uterine  myoma. 

13.  Cancer  of  the  sigmoid  flexure. 

14.  Abscess  due  to  inflammation  of  the  vermiform 

appendix. 

15.  Tumours  of  the  sacrum  or  innominate  bone. 

16.  Tumours  of  the  broad  ligament,  including  hydatid 

cysts. 


300         Diseases  of  the  Fallopian  Tubes. 

In  a  few  cases  laparotomy  has  been  performed,  and 
nothing  found. 

I* civic  pain. — The  most  misleading  symptom  of 
all  I's,  pai7i^  especially  when  most  pronounced  at  the  men- 
strual period.  Such  pain  has  been  described  as  ovarian 
neuralgia,  and  has  induced  surgeons  in  some  instances 
to  remove  the  ovaries,  even  in  the  absence  of  physical 
signs.  On  two  occasions  such  ovaries  have  been  sub- 
mitted to  me  for  microscopical  examination,  but  I  have 
not  succeeded  in  detecting  any  evidence  of  disease  in 
them. 

This  is  consonant  with  what  we  find  in  other  organs. 
Young  women  often  suffer  from  pain,  sometimes  of  severe 
character,  in  the  breast,  but  the  most  careful  examination 
fails  to  reveal  any  lesion  which  explains  the  painful 
sensation.  In  the  same  way,  highly  sensitive  nervous 
men  complain  of  pain  in  the  testicles. 

On  one  occasion  I  obtained  the  advice  of  Sir  James 
Paget  concerning  a  young  lady  who  experienced  severe 
pain  in  the  left  breast,  for  which  no  reasonable  cause 
could  be  assigned.  This  acute  observer  stated  he  had 
frequently  noticed  that  in  young  women  interested  in 
the  study  of  \}!\&fine  arts.,  sensations,  which  in  others  cause 
little  or  no  concern,  sometimes  are  frequently  in  them 
the  source  of  inconvenience  and  much  suffering. 

On  looking  over  the  clinical  notes  of  my  cases  I 
find  a  great  deal  of  evidence  that  supports  this  highly 
important  observation. 

It  must  be  observed  that  the  removal  of  painful 
organs  in  such  cases  does  not  destroy  the  pain.  It  may 
relieve  for  a  time,  but  sooner  or  later  pain  returns  with 
its  former  intensity,  resembling  in  this  respect  inveterate 
trigeminal  neuralgia. 


30I 


CHAPTER  XXVI. 

THE    TREATMENT    OF    SALPINGITIS    AND    OOPHORITIS. 

The  treatinejit  of  salpingitis,  whether  secondary  to  septic 
changes  originating  in  the  uterus  or  in  the  vagina,  is 
much  the  same. 

Acute  salpiug'itis  ensuing  upon  labour  or  abortion 
is  usually  described  as  puerperal  fever.  The  principles  of 
treatment  are  very  simple  :  they  are  absolute  and  pro- 
longed rest  in  bed,  extreme  cleanliness,  and  attention  to 
the  bowels  are  the  most  important. 

In  gonorrliceal  isalping'itis,  during  the  acute 
stages,  absolute  rest  in  bed  should  be  enjoined,  and  mild 
vaginal  injections  ought  to  be  freely  employed.  It  must 
be  remembered  in  treating  these  cases  that  the  pelvic 
pain  of  which  the  patients  complain  indicates  that  the 
inflammation  has  extended  from  the  tubes  to  the  peri- 
toneum, and  that,  in  addition  to  salpingitis,  there  is  in- 
flammation localised  to  the  pelvic  peritoneum. 

In  the  early  stages,  especially  when  the  symptoms 
supervene  upon  abortion,  it  is  difficult  to  accurately  dis- 
criminate between  salpingitis  and  cellulitis  of  the  broad 
ligament ;  this  is  an  additional  reason  for  enjoining 
absolute  rest  in  order  to  prevent  the  formation  of  a  pelvic 
abscess. 

The  treatment  of  the  early  stages  of  salpingitis  is  very 
simple,  yet  it  is  not  too  much  to  state  that  if  more  atten- 
tion were  directed  to  this  disease  at  its  commencement, 
many  women  would  be  saved  much  subsequent  misery 
and  pain. 


302         Diseases  of  the  Fallopian  Tubes. 

When  the  mucous  membrane  of  the  tubes  has  become 
seriously  damaged,  the  tube  itself  fixed  by  adhesions  to 
surrounding  structures,  the  ovary  involved  in  the  inflam- 
mation, and  the  lumen  of  the  tube  occluded,  then  drugs 
are  of  little  avail. 

When  the  patients  are  in  good  circumstances,  and 
able  to  lead  an  idle  life,  they  often  become  chronic 
invalids.  It  is  such  patients  who  are  able  to  indulge  in 
the  luxury  of  visits  to  Continental  health  resorts  to  try 
the  effects  of  various  springs  and  baths,  and  the  mud  or 
moor-baths  of  Bohemia. 

In  women  who  have  to  perform  household  duties, 
and  even  get  their  own  living,  a  life  of  luxury  and  ease 
is  out  of  the  question.  Under  such  conditions  it  is 
necessary  to  adopt  more  radical  measures. 

The  ordinary  rules  of  surgery  suggest  that  when  the 
physical  signs  and  history  of  the  case  indicate  that  the 
tubes  are  occluded  and  distended  with  pus  or  other  fluid, 
producing  so  much  pain  and  inconvenience  as  to  cause 
the  patient  to  lead  the  life  of  a  chronic  invalid,  then  it  is 
justifiable  to  remove  them  by  abdominal  section.  To 
dilate  and  scrape  the  interior  of  the  uterus  in  such  cases,  to 
tap  them  through  the  vagina,  or  attempt  to  disperse  them 
by  electricity,  by  moor-baths,  or  by  mild  purgatives,  are 
modes  of  treatment  which  can  only  be  described  as 
ridiculous,  and  in  many  cases  they  are  highly  dangerous. 
It  must  be  confessed  that  the  whole  difficulty  in  the 
treatment  of  these  cases  lies  in  the  diagnosis.  If  the 
surgeon  could  be  sure  his  patient  were  suffering  from  a 
collection  of  pus  in  the  tubes,  he  would  have  no  more 
hesitation  in  removing  them  than  he  feels  in  recom- 
mending the  excision  of  a  sacculated  and  suppurating 
kidney. 

It  is  to  be  hoped  that  now  so  much  close  attention 
is  being  devoted  to  these  diseases,  we  shall  be  able  to 


The  Treatment  of  Salpingitis.  303 

formulate  some  more  certain  signs  of  the  presence  of  pus 
in  the  tubes,  which  will  enable  us  to  advocate  the 
necessary  lines  of  treatment  with  more  confidence. 

Removal  of  the  Fallopian  tubes  and  ovaries  is 
necessary  in  the  following  conditions  : — 

1.  Pyosalpinx  and  tubo-ovarian  abscess. 

2.  Hydrosalpinx. 

3.  Tubercular  salpingitis. 

4.  Ovarian  abscess. 

In  these  affections  the  operation  is  not  only  justifiable, 
but  it  is  the  only  means  of  radical  treatment.  It  is 
sanctioned  and  practised  by  those  who  have  had  the 
greatest  experience  in  ovariotomy,  and  an  examination 
of  their  lists  of  recorded  cases  shows  that,  under  the 
impression  they  were  dealing  with  ovarian  or  parovarian 
cysts,  they  have  removed  Fallopian  tubes,  sometimes 
filled  with  pus,  sometimes  with  less  harmful  fluid. 

In  iuhercidar  salpingitis  the  operation  should  only  be 
undertaken  when  there  is  no  evidence  of  tubercle  in 
other  organs,  such  as  the  lungs,  bladder,  kidneys,  or 
peritoneum. 

The  records  of  operations  for  this  form  of  tubal 
disease  show  that  they  are  attended  with  a  very  high 
rate  of  mortality,  and  convalescence  is,  as  a  rule,  pro- 
longed. 

The  conservative  measure  advocated  under  the  term 
of  salpingostomy  is  as  yet  in  its  infancy. 

Hernia  of  the  ovary* — Herniated  ovaries  require 
removal  when  they  are  a  source  of  pain,  and  in  women 
who  cannot  wear  a  truss.  The  operation  has  been  almost 
entirely  confined  to  those  who  have  to  maintain  them- 
selves by  hard  work;  a  very  large  proportion  of  the 
patients  are  domestic  servants.  The  operation  is  per- 
formed as  for  inguinal  hernia  ;  the  ligatured  stump  should 
be  returned  into  the  peritoneal  cavity. 


304         Diseases  of  the  Fallopian  Tubes. 

the  operative  treatment  of  neurotic    conditions 
associated  with  the  ovaries. 

The  removal  of  the  ovaries  and  tubes  has  been 
recommended  and  practised  for  the  reUef  of  such  con- 
ditions as  : — ■ 

1.  Epilepsy  and  insanity. 

2.  Dysmenorrhoea. 

3.  Ovarian  neuralgia. 

4.  Prolapsed  ovary. 

In  this  group  the  procedure  has  not  been  followed 
by  encouraging  results  ;  indeed,  they  are  so  unsatisfactory 
that  those  who  have  had  greatest  experience  in  this  class 
of  surgery  are  almost  unanimous  in  condemning  the 
operation,  save  under  very  exceptional  conditions  ;  even 
then  the  operator  should  safeguard  himself  by  seeking 
confirmatory  opinion. 

It  would  be  tedious  and  useless  to  enter  into  a  full 
discussion  of  the  reasons  that  have  been  urged  against 
the  routine  employment  of  so  severe  an  operation  for 
the  relief  of  these  neurotic  affections.  The  chief  objec- 
tions are  summarised  in  the  following  clauses  : — 

1.  In  a  very  large  proportion  of  cases  the   removal 

of  the   ovaries   and   tubes   fails   to   relieve  the 
patient. 

2.  In    many     cases    the    operation    aggravates    the 

symptoms. 

3.  In  only  a  very  small  proportion  of  cases  has  there 

been  pei'maiient  improvement. 

4.  Many  cases  reported  a  few  weeks  or  months  after 

the     operation    as    cured     have     subsequently 
relapsed. 
The  objections  may   be  briefly  expressed  in  this  way  : 
The  inherent  iHsks  of  the  operation  and  the  uncertainty  of 
the  result. 


Oophorectomy  for  Ovarian  Pain.         305 

It  has  been  pertinently  suggested  that  //  the  positive 
benefits  of  the  operatiofi  were  as  assured  as  its  rate  of 
recovery^  the  opposition  to  it  would  soon  cease.  In  answer 
to  this,  it  should  be  remembered  that  we  are  not  in 
possession  of  trustworthy  statistics  on  which  to  base 
an  even  approximate  rate  of  mortality. 

The  arguments  adverse  to  removal  of  the  ovaries 
simply  because  they  are  believed  to  be  a  source  of 
mental  alienation  or  neuralgia,  in  the  absence  of  physical 
signs  indicating  disease  of  these  organs,  are  many. 
Those  interested  in  the  subject  will  find  them  ably 
set  forth  in  articles  by  Sir  Spencer  Wells*  and  Dr. 
Playfair.t 

The  mortality  of  oophorectomy  as  compared  with 
ovariotomy  is  distinctly  higher.  All  experienced  ovari- 
otomists  are  unanimous  on  this  point. 

It  is  a  significant  fact  that  many  surgeons  who  have 
published  long  lists  of  ovariotomies  in  order  to  parade 
their  manipulative  skill  have  abstained  from  publishing 
in  the  same  way  records  of  their  oophorectomies.  Tait,i 
Keith,§  Meredith,  1 1  and  a  few  others,  have  published  Hsts 
of  this  operation,  but  we  have  little  collective  evidence 
of  Its  risks  in  the  hands  of  the  average  surgeon. 

In  many  instances  where  oophorectomy  has  been 
carried  out  for  the  relief  of  pain,  unaccompanied  by 
objective  signs  in  the  pelvic  viscera,  the  operators  have 
pointed  out,  in  justification  of  the  interference,  that  the 
ovaries  were  cystic.  There  is  a  subtlety  in  this  excuse. 
The  so-called  practical  surgeon,  as  a  rule,  affects  to  scoff 
at  pathology.     Such  men,  I  find,  apply  the  term  ovarian 

*  Internatiofial  Jou7-nal  of  the  Medical  Sciences,  vol,  xcii.  p.  455. 
f  Trans.  Obstet.  Soc,  vol.  xxxiii.  p.  7. 
j  Diseases  of  the  Ovat'ies  ;  1883. 
'^  Edi?i.  Med.  Journal,  1887,  p.  811. 
II  Med.-Chir.  Tra?is.,  vol.  Ixxii.  p.  53. 

U 


3o6         Diseases  of  the  Fallopian  Tubes. 

to  cysts  of  the  size  of  a  Tangerine  orange  and  upwards. 
When  they  excise  an  ovary  for  pain  they  cut  into  the 
organ,  and  finding  ripe  follicles,  describe  it  as  a  cystic 
ovary.  Every  normal  ovary  is  cystic,  hence  an  excuse  is 
readily  found.  The  ovary  represented  in  Fig.  2  is  a 
perfectly  normal  gland;  it  is  cystic,  but  the  cysts  are 
mature  follicles.  Many  such  have  been  removed  under 
the  impression  that  the  presence  of  such  cysts  justified 
removal.  The  ovaries  are  in  many  respects  analogous 
to  the  breasts.  A  healthy  woman  may  have  small 
breasts,  and  another  her  equal  in  age  and  size  perhaps 
possesses  a  pair  of  large  plump  mammae,  yet  both  glands 
fulfil  their  function.  The  same  is  equally  true  of  the 
ovaries.  That  shown  in  Fig.  2  was  as  healthy  and 
capable  as  the  large  gland  in  Fig.  i. 

In  an  organ  liable  to  vary  so  much,  and  naturally 
concerned  in  forming  cysts,  it  is  not  surprising  that 
healthy  ovaries  should  be  frequently  mistaken  by  the  in- 
experienced for  diseased  organs. 


fart   ra« 
TUBAL    PREGNANCY. 


CHAPTER    XXVII. 

TUBAL    PREGNANCY. 

In  every  female  mammal  above  Monotremata  there  is  a 
section  of  the  genital  tract  intervening  between  each 
abdominal  ostium  and  the  uterus  in  which,  under  normal 
conditions,  impregnated  ova  are  not  retained.  These 
.narrow  portions  are  the  Fallopian  tubes,  and  they  serve 
to  conduct  the  eggs  from  the  ovaries  to  the  uterus.  It  is 
usually  taught  that  in  the  hum.an  female  the  tubes  are  the 
meeting  place  of  ova  and  spermatozoa,  but  this  is  pure 
conjecture.  The  opinion  that  the  spermatozoa  pass  up 
the  tube  and  disport  themselves  among  the  fringes  at 
the  abdominal  orifice  is  unsupported  by  facts ;  so  is  the 
fable  that  the  Fallopian  tubes  are  able  to  grasp  the  ovary 
and  secure  the  ovum  at  its  dehiscence. 

Hyrtl,  in  his  classical  Lehrbuch  der  Anatoniie, 
writes  : — "  The  fimbriae  at  the  abdominal  ostium  appear  as 
if  they  were  bitten  or  torn  away  ;  hence  the  term  morsus 
diabolt.  The  devil  has  since  Eve's  time  had  more  to  do 
with  womenkind  than  with  men."  Der  Schwabenspiegel 
(1273)  says  :  "  Mulier  est  malleus^  per  quern  diabolus  inollit 
et  malleat  universum  immdiimr  The  term  morsus 
diaboli  is  borrowed  from  botany.  The  plant  Scabiosa 
succisa,  formerly  much  used  owing  to  its  healing  pro- 
perties, was  called  "devil's-bit  scaby,"  because  its  root 
presents  a  premorse,  or  bitten- off,  appearance.  The 
u  2 


3o8  Tubal  Pregnancy. 

virtues  of  this  plant  to  suffering  humanity  rendered  it  an 
object  of  dishke  to  the  devil,  and  the  superstitious  old 
herbalists  believed  that  in  his  wrath  he  bit  off  the  root. 
There  is,  however,  little  resemblance  between  the  root 
of  the  plant  and  the  fringed  ostium  of  the  Fallopian  tube, 
but  Doran  has  pointed  out  the  striking  resemblance 
which  exists  between  it  and  \\\^floiver  of  the  devil's-bit 
scaby. 

It  is  more  reasonable  to  believe  that  impregnation 
occurs  normally  in  the  uterus,  and  that  when  fecundation 
occurs  in  the  tubes  it  is  accidental,  and  tubal  gestation 
is  the  consequence. 

Concerning  the  cause  of  tubal  pregnancy  we  know 
little. 

In  many  instances  it  happens  in  women  who  have 
been  married  eight,  ten,  and  even  twenty  years,  and  have 
never  before  been  pregnant,  yet  the  first  pregnancy 
occurs  in  the  tube.  In  one  of  my  cases  the  patient  had 
been  twice  married,  and  had  lived  in  wedlock  seventeen 
years,  and  then  became  the  victim  of  tubal  gestation, 
never  having  been  pregnant  before.  In  other  cases  it 
follows  a  normal  pregnancy  or  abortion  by  one,  two, 
three,  ot  four  months.  It  may  occur  as  a  first  pregnancy 
in  a  woman  between  thirty  and  forty  years  of  age  or  in 
a  girl  of  twenty  ;  in  the  newly-married  or  the  mother  of 
a  large  family.  Parry  *  has  shown  it  occurs  most  fre- 
quently after  long  intervals  of  sterility,  and  it  may 
occur  twice  in  the  same  patient,  as  Dr.  Hermanj  has 
indisputably  demonstrated. 

The  fact  that  pregnancy  occurs  in  the  tube  after  a 
long  period  of  sterility  in  women  who  have  borne 
children    has   given  colour  to  the    suggestion  that  the 


*  ExtKiX-Utcrine  Pregnancy. 

t  Brit,  Med.  Journal,  vol.  ii.  p.  722  ;  1890. 


Salpingitis  and  Tubal  Pregnancy.        309 

patients  have  suffered  from  desquamative  salpingitis,  and 
the  destruction  of  the  proper  cih'ated  epithehum  will 
account  for  occurrence  of  tubal  gestation,  inasmuch  as 
it  puts  the  mucous  Hning  of  the  tubes  into  a  condition 
exactly  similar  to  that  of  the  uterus  after  menstruation. 
Mr.  Lawson  Tait  asserts  that  "  the  uterus  alone  is 
the  seat  of  normal  conception ;  that  as  soon  as  the 
ovum  is  affected  by  the  spermatozoa  it  adheres  to  the 
mucous  surface  of  the  uterus ;  that  the  function  of 
the  ciliated  hning  of  the  Fallopian  tubes  is  to  prevent 
spermatozoa  entering  them,  and  to  facilitate  the  progress 
of  the  ovum  into  the  proper  nest ;  further,  that  the 
phcations  and  crypts  of  the  mucous  membrane  lodge 
and  retain  the  ovum  either  till  it  is  impregnated,  or  till 
it  dies  or  is  discharged."  * 

The  above  view  is  entirely  a  speculation,  and,  as  far 
as  I  am  aware,  no  one  has  attempted  to  substantiate  or 
disprove  the  causative  relation  between  desquamative 
salpingitis  and  tubal  gestation.  I  have  made  it  the 
subject  of  prolonged  investigation,  and  am  prepared  to 
state  that  it  contains  an  element  of  truth,  but  it  does  not 
hold  in  all  cases.  In  the  first  place,  salpingitis  so  severe 
as  to  produce  destruction  of  the  tubal  epithelium  causes 
such  profound  changes  in  the  tubes  themselves  as  to  lead 
to  stricture  and  complete  occlusion  of  the  abdominal 
ostia;  it  is  exceedingly  rare  to  meet  with  tubes 
denuded  of  their  epithelium  and  the  abdominal  ostia 
patent.  It  is,  however,  well  to  bear  in  mind  that 
salpingitis,  even  of  a  mild  type,  may  so  affect,  the  tubal 
mucous  membrane  as  to  retard  or  altogether  prevent  the 
passage  of  ova,  and  an  examination  of  pregnant  tubes 
shows  that  salpingitis  of  a  mild  type,  and  without  even 
partial    destruction  of  the  epithelium,  will   lead  to  the 

*  Ectopic  Pregnancy,  p.  4, 


3IO  Tubal  Pregnancy. 

detention  of  ova  and  expose  them  to  spermatozoa,  which 
may  wander  into  the  tubes.  On  the  other  hand,  in 
several  specimens  of  very  early  tubal  pregnancy  I  have 
failed,  even  after  the  most  careful  microscopic  examina- 
tion, to  find  any  evidence  of  old  salpingitis  or  loss  of 
epithelium.  The  museum  of  St.  Mary's  Hospital  con- 
tains an  interesting  specimen  in  this  relation.  A  single 
woman  aged  twenty  years  was  suddenly  seized  with 
severe  abdominal  pain,  followed  by  symptoms  indicative 
of  internal  haemorrhage..  Rupture  of  a  pregnant  tube 
was  suggested  as  the  cause,  but  disregarded,  as  the 
hymen  was  intact.  Death  occurred  three  days  after 
rupture.  At  the  necropsy  a  ruptured  sac  was  found  in 
the  left  Fallopian  tube.  In  company  with  the  curator, 
Mr.  J.  J.  Clarke,  I  examined  the  sac,  and  found  it  to 
contain  chorionic  villi.  Sections  were  prepared  from  the 
tube,  but  the  epithelium  was  intact,  and  no  evidence  of 
salpingitis  was  detected. 

Early  in  1890  I  saw  in  consultation  with  Dr.  Owen 
Coker  a  young  married  woman  who  presented  the  signs 
of  rupture  of  a  gravid  tube.  The  diagnosis  was  con- 
firmed, for  on  opening  the  abdomen  I  removed  from  a 
large  rupture  in  the  left  tube  an  apoplectic  ovum  the  size 
of  a  bantam's  egg.  The  right  tube  and  ovary  were 
bound  down  by  dense  adhesions.  The  patient  died 
on  the  third  day  after  operation,  from  peritonitis  ;  this 
was  due  to  leakage  of  pus  from  the  right  tube,  which 
was  converted  into  a  pyosalpinx ;  the  mucous  mem- 
l)rane  presented  all  the  characters  of  an  old-standing 
salpingitis. 

Unfortunately,  few  operators  take  the  trouble  to  ex- 
amine the  tubes  in  such  ca.ses.  Dr.  Griffith  *  reported 
a  case  of  tubal  pregnancy  which    terminated  fatally  at 

*  Path.   Trans. ,  vol.  xxxiii.  p.  227. 


The  Changes  in  the  Tube.  311 

an  early  date.  Both  tubes,  though  apparently  healthy 
to  the  naked  eye,  were  found  on  microscopic  examina- 
tion to  exhibit  marked  evidence  of  disease.  The 
mucous  membrane  was  quite  denuded  of  epithelium, 
and  "the  conditions  present  appeared  to  indicate  a 
comparative  recovery  from  a  destructive  inflammation 
of  the  mucous  membrane."  The  woman  had  been 
married  eleven  years,  but  had  never  before  been 
pregnant. 

An  impregnated  ovum  may  lodge  in  any  part  of  the 
tube ;  as  the  course  of  events  varies  according  to  its 
position,  it  will  be  necessary  to  consider  separately  the 
changes  that  ensue  when  the  ovum  is  arrested  in  the 
tube  proper,  or  in  that  section  which  traverses  the  walls 
of  the  uterus.  Gestation  in  the  tube  proper  will  be 
called  iiibal  pregnancy ;  in  the  uterine  segment,  tubo- 
iiterine  pregnaiicy.  The  last  variety  will  be  considered  in 
a  separate  chapter. 

The  changes  which  follow  the  arrest  of  an  impreg- 
nated ovum  in  the  tube  will  be  considered  under  the 
following  heads  : — 

1.  The  changes  in  the  tube  and  the  mode  of  closure 

of  the  abdominal  ostium. 

2.  Pathological  changes  affecting  the  ovum. 

3.  Tubal  abortion. 

4.  Rupture  of  the  gestation  sac. 

5.  The  formation  of,  and  the  pathological  changes  in, 

the  placenta. 
The  eliaiig-es  in  the  tiihe.— During  the  first  month 
or  six  weeks  that  portion  of  the  tube  in  which  the  ovum 
is  lodged  becomes  very  vascular  and  much  thickened. 
This  has  been  described  as  hypertrophy,  but  it  differs 
greatly  from  the  enlargement  exhibited  by  a  gravid  uterus. 
The  latter  is  due  to  an  increase  in  size  and  number  of 
the  muscle  cells,  whereas  in  a  gravid  tube  the  increase  in 


312  Tubal  Pregnancy. 

size  is  mainly  due  to  turgescence.  This  statement  is  the 
outcome  of  the  microscopic  examination  of  eight  speci- 
mens of  gravid  tubes  between  the  fourth  and  twelfth 
weeks  of  gestation.  Herman*  is  of  opinion  that  the  tubes 
hypertrophy,  but  not  to  the  same  extent  as  the  uterus. 
In  some,  the  walls  of  the  tube  in  contact  with  the  ovum 
seem  to  stretch  and  thin  from  the  beginning  of  the 
gestation.  The  rapidity  of  the  thinning  varies  in  different 
tubes,  and  this  is  doubtless  due  to  the  fact  that  under 
normal  conditions  the  Fallopian  tubes  not  only  vary  in 
length,  but  in  thickness.  In  some  individuals  they 
scarcely  exceed  in  thickness  the  vasa  deferentia  of  the 
male,  or  resemble  the  narrow  tubes  of  the  mare  or  cow. 
As  the  tube  expands  from  the  enlargement  of  the  ovum 
within  it,  the  mucous  membrane  is  stretched  and  its 
glandular  folds  effaced.  Occasionally  a  few  of  the  plicae 
will  project  within  the  tube  as  long  straggling  processes. 

Whilst  these  changes  are  in  progress,  curious  altera- 
tions are  taking  place  at  the  abdominal  ostium,  which,  in 
most  cases,  gradually  bring  about  its  occlusion,  an  event 
usually  completed  by  the  eighth  week.  During  the  first 
four  weeks  the  congestion  of  the  parts  causes  turgescence 
of  the  fimbriae  as  well  as  of  the  muscular  and  serous 
tissues  adjacent  to  them.  When  the  parts  are  thus 
swollen,  the  margin  of  peritoneum  adjacent  to  the  ostium 
is  very  conspicuous,  and  forms  an  irregular. ring  over  the 
fimbriae.  In  another  fourteen  days  this  ring  projects  be- 
yond the  fimbriae,  and,  lastly,  contracts  and  hermetically 
closes  the  ostium.  Two  stages  in  this  process  are  repre- 
sented in  Figs.  94  and  95. 

Occasionally  specimens  will  be  found  at  the  tenth  or 
twelfth  week,  and  even  later,  in  which  the  ostium  is  only 


*  Fowler's  Dictionary  of  Medicine ;  article,  "Extra-Uterine  Gesta- 
tion." 


TUBE 


Fig.  94. — Gravid  Fallopian  Tube  at  the  sixth  week. 
The  walls  are  extremely  thin ;   Its  ostium  is  partially  closed. 


Fig.    95.— Gravid    Fallopian   Tube   at   the   tenth   week,    showing   complete 
occlusion  of  the  Ostium. 

.  o.  Ovary  ^\ith  corpus  luteum. 


314  Tubal  Pregnancy. 

partially  closed.  I  have  recorded  *  such  a  case  in  which 
the  clinical  history  and  the  size  of  the  embryo  showed 
that  the  pregnancy  had  advanced  to  the  twelfth  week. 
The  history  of  the  case  also  indicated  that  the  tube  had 
ruptured  about  the  sixth  week  of  gestation,  and  the 
embryo  dislocated  between  the  layers  of  the  mesome- 
trium.  This  view  is  supported  by  the  fact  that  the 
degree  of  closure  manifested  by  the  ostium  corresponds 
to  that  seen  in  tubes  examined  at  the  sixth  week.  This 
should  be  borne  in  mind,  or  such  cases  may  lead  to 
error.  To  prevent  which,  it  may  be  stated  that  if  the 
tube  rupture  before  the  ost'mni  is  completely  dosed,  and  the 
patient  survive  the  accident,  the  occluding  process  is  arrested. 
Pathological  cliaug'es  in  eoiinection  Avitli 
the  oviiHi.— After  impregnation,  the  most  important 
change  which  occurs  in  connection  with  the  investing 
membranes  is  the  growth  of  cellular  dendritic  processes, 
known  as  chorionic  villi.  When  thoroughly  developed,  the 
villi  cause  the  exterior  of  the  ovum  to  present  a  shaggy 
appearance,  and  serve  to  fix  it  to  the  adjacent  mucous 
membrane,  whether  uterine  or  tubal ;  they  soon  become 
permeated  by  vessels  conveyed  to  them  from  the  aorta  of 
the  embryo  by  the  allantois.  Subsequently  the  greater 
number  of  the  villi  atrophy;  those  which  persist  increase 
greatly  in  size  and  complexity,  and  ultimately  form  the 
foetal  portion  of  the  placenta.  It  matters  not  whether  the 
gestation  be  tubal  or  uterine,  the  life  of  an  ovum  is  pre- 
carious until  the  placenta  is  well  formed,  for  the  union 
between  the  ovum  and  the  mucous  membrane  is  not  very 
intimate  when  it  depends  on  the  chorionic  villi  in  their  early 
stages.  The  result  is  that  from  a  variety  of  causes  the  ovum 
may  be  dislodged  in  part,  or  entirely,  from  its  relation 
to  the  mucous  membrane ;  such  dislodgement  is  always 

*  Trans.  Obstct.  Soc,  London,  vol.  xxxiii.  p.  70. 


Tubal  Moles.  315 

accompanied  with,  and  in  very  many  instances  actually 
caused  by,  haemorrhage  among  the  chorionic  villi.  Practi- 
tioners are  familiar  with  rounded  bodies  discharged  from 
the  uteri  of  pregnant  women,  accompanied  by  profuse 
haemorrhage.  These  bodies  are  known  by  various  names, 
"  blighted  ovum,"  "  fleshy  or  carneous  mole,"  "  apo- 
plectic ovum,"  etc.  They  are  so  common  that  most 
pathological  museums  usually  contain  several  specimens, 
and  few  matrons  terminate  their  reproductive  period  of 
life  without  producing  one  or  more  examples  of  the  fleshy 
mole.  The  clinical  expression  for  the  event  is  abortion. 
When  an  apoplectic  ovum  is  examined  soon  after  its  dis- 
charge, it  resembles  a  firm  blood-clot  in  colour  and  con- 
sistence. On  dividing  it,  a  cavity  containing  fluid, 
sometimes  straw-coloured,  sometimes  stained  red  from 
admixture  with  blood,  is  found.  The  walls  of  this  cavity 
are  smooth  and  lined  with  amnion,  and  often  a  misshapen 
foetus  is  contained  within,  or  the  stump  of  the  umbilical 
cord ;  frequently  no  trace  of  an  embryo  can  be  detected. 
A  fleshy  mole  is  really  an  early  ovum  with  its  membranes, 
into  which  blood  has  been  extravasated.  The  extent  of 
the  extravasation  varies ;  occasionally  the  blood  invades 
the  amniotic  cavity  and  overwhelms  the  embryo.  Fleshy 
moles  similar  to  those  arising  in  the  uterus  occur  in  con- 
nection with  tubal  gestation,  and  they  appear  to  be  more 
common  between  the  fourth  and  eighth  weeks  than  at  any 
other  period.  Their  formation  is,  in  most  cases,  attended 
with  disastrous  consequences  to  the  individual  unfortunate 
enough  to  become  the  victim  of  tubal  pregnancy.  This 
fact  alone  should  cause  them  to  be  carefully  studied. 

In  October,    1889,  I    communicated   to    the  Royal 
Medico-Chirurgical  Society  *  two  cases  of  fleshy  moles 

*  "A  Case  of  Tubal  Pregnancy  :  "  Medico-Chirurgical  Transactions, 
vol.  Ixxiii.  p.  55.  Keller  has  since  described  three  and  Orthmann  ten 
cases  {Zeitschrififiir  Gehurtshiilfe,  1890). 


3i6  Tubal  Pregnancy. 

from  the  Fallopian  tubes,  which  I  had  removed  from 
patients,  and   showed  that  they  in  no  way  differed  from 
apoplectic  ova  so  frequently  discharged  from  the  uterus. 
Since  then  I  have  had  opportunities  of  dissecting  and 
examining  several  specimens.     It  is  of  some  importance 
to   be    familiar   with    their  chief  features,    because   the 
existence  of  a  fleshy  mole  is  certain  proof  of  pregnancy. 
When  the  extravasation  of  blood  is   extensive  and  ob- 
literates the  amniotic  cavity,  it  causes  doubt  whether  we 
are  dealing  with  a  lump  of  blood  coagulum   or  an   apo- 
plectic ovum ;  for  it  must  be  borne  in  mind  that  an  ovum 
of  this  character  detained  for  many  days  in  the  pelvis 
after  its  discharge  from  the  tube,  or  if  it  be  lodged  be- 
tween the  layers  of  the  broad  ligament  for  many  weeks, 
becomes   laminated  and  hard.     Under  such  conditions 
its  nature  can  only  be  satisfactorily  determined  by  finding 
an  embryo  or  its  remains  imprisoned  in  the  clot,  or  by 
ascertaining  the  existence  of  chorionic  villi.     On  several 
occasions  I  have  been  able  to  demonstrate  the  existence 
of  tubal  pregnancy  by  the  presence  of  villi  alone.    In  size, 
tubal  moles  vary  greatly,  depending,  of  course,  on  the 
date  at  which  the  haemorrhage  happens.      My  smallest 
specimen   equals  in   size  the  kernel  of  a  cob-nut ;    the 
largest  is  as  big  as  a  Tangerine  orange.     The  size  of  an 
apoplectic   ovum    depends    on   the    date   at   which    the 
haemorrhage  occurs,  as  well  as  on  the  amount  of  blood 
extravasated    into    the    membranes.      In    an    interesting 
specimicn  which  Dr.  Herman  removed  before  rupture,  he 
found,  on  sUtting  open  the  sac,  that  "  haemorrhage  had 
taken  place  into  the  chorion,  and  the  coagulated  blood 
made    the    interior    of  the    sac    precisely   resemble    the 
interior    of  the    apoplectic    ova    so    numerous    in    our 
museums."      In  this  valuable    specimen  the   blood  was 
extravasated   into   the   membranes   of  the    ovum   only ; 
there  was  no  free  blood  in  the  tube.     That  an  apoplectic 


Tubal  Moles.  317 

ovum  is  not  formed  merely  by  the  immersion  of  its 
membranes  in  blood  is  demonstrated  by  cases  in  which, 
after  rupture  of  a  tubal  gestation  sac  from  violence,  the 
ovum  has  remained  for  several  hours  soaking  in  blood, 
yet  when  removed  from  the  body  its  membranes 
and  villi  have  been  found  delicate  and  transparent. 
The  same  condition  occurs  in  early  ova  discharged 
from  the  uterus.  It  would  appear  that  the  forma- 
tion of  a  mole  in  the  tube  is  a  frequent  means  of 
inducing  tubal  abortion  or  rupture.  The  museum  of 
St.  Bartholomew's  Hospital  contains  a  specimen  which 
illustrates  this.  It  is  described  thus,  under  the 
heading  "  Haematoma  of  the  Broad  Ligament": — -"The 
uterus  and  its  appendages  :  between  the  layers  of  the 
right  broad  ligament  is  a  globular  cyst  about  as  big  as  a 
walnut,  the  wall  of  which,  in  the  recent  state,  was  seen  to 
be  formed  by  the  separated  layers  of  the  ligament;  its 
cavity  was  filled  with  recent  blood  coagula.  On  the 
anterior  aspect  of  the  cyst  were  two  small,  recently 
formed,  irregular  openings.  From  a  patient  twenty-five 
years  of  age,  who,  while  in  the  hospital  for  treatment  of 
warts  on  the  vulva,  was  suddenly  attacked  with  the 
symptoms  of  internal  haemorrhage,  and  died  in  twelve 
hours.  At  \\\Q.  post  mortem  examination  the  cavity  of  the 
peritoneum  contained  five  pints  of  recently  effused, 
loosely  coagulated  blood ;  and  dark  fluid  blood  oozed 
slowly  from  the  openings  in  the  cyst  above  described.  A 
very  careful  examination  of  the  blood  cyst  failed  to  dis- 
cover the  source  of  the  haemorrhage.  There  was  no 
evidence  of  the  existence  of  uterine  pregnancy,  and  no 
ruptured  vessel  was  detected.  It  was  uncertain  whether 
the  patient  was  menstruating  at  the  date  of  the  attack  " 
(2940). 

Thanks  to  the  courtesy  of  the  present  curator,  Mr. 
Edgar  Willett,  an  opportunity  has  been  afforded  me  of 


^I' 


Tubal  Pregnancy, 


examining  and  sketching  this  interesting  specimen.  On 
opening  the  parts  it  was  clear  that  the  blood-clot  was  not 
between  the  layers  of  the  broad  ligament,  but  was  entirely 


CESTAT 


Fig.  96. —  Left  Fallopian  Tube  and  adjacent  portion  of  the  Uterus. 
(Museum,  St.  Bartholomew's  Hospital.) 

The  tube  is  occupied  by  an  apoplectic  ovum  or  mo.e. 


within  the  tube ;  its  histology  showed  clearly  enough  the 
supposed  blood-clot  to  be  really  an  apoplectic  ovum,  and 
that  the  woman  was  the  victim  of  a  tubal  pregnancy, 
which  proved  fatal  about  the  fourth  or  fifth  week 
(Fig.  96). 


Tubal  Moles. 


319 


Many  similar  specimens  are  displayed  in  the  museums 
attached  to  metropolitan  hospitals,  and  described 
under  a  variety  of  names,  but  their  ovuline  nature 
has  been  completely  overlooked. 

It  will  be  useful  to  briefly  summarise  the  characters 
by  which  a  mole  found  in  a  Fallopian  tube,  loose  in  the 
pelvis,  or  between  the  layers  of  the  broad  ligament,  may 
be  identified. 

{a)  When  recent,  it  resembles,  in  external  appearance, 
a  piece  of  blood  coagulum  of  a  dark  red  colour.    If  it  has 


APOPLECTIC    OVU.M 
Fig.  97. — Apoplectic  Ovum,  or  Tubal  Mole.     Natural  size. 

been  free  in  the  peritoneal  cavity  or  lodged  between  the 
layers  of  the  broad  ligament  for  several  da}  s  or  weeks,  it 
will  be  of  a  yellowish  colour  externally  (due  to  a  layer  of 
fibrin),  and  quite  firm  and  hard. 

{b)  Large  tubal  moles  are  often  elliptical  in  shape 
(Fig.  97).     Small  ones  are  more  or  less  circular. 

{c)  The  average  size  of  moles  is  that  of  a  walnut. 
They  rarely  exceed  in  size  a  Tangerine  orange.  When 
smaller  than  a  cob-nut  they  are  usually  lost  in  the  clot. 

{d)  The  presence  of  a  central  cavity  lined  with  a 
smooth  membrane — the  amnion.  The  cavity  may  con- 
tain an  embryo ;  very  frequently  the  cavity  is  destroyed 
early,  or  the  mole  may  be  ruptured  and  allow  it  to  escape 
with  the  blood-clot. 


320 


Tubal  Pregnancy. 


{e)  Sections  of  the  clot  will  show  under  the  micro- 
scope chorionic  villi.  The  most  trustworthy  sign  of  all 
is  the  presence  of  an  embryo.  Next  in  value  is  the 
existence  of  chorionic  villi,  and  these  may  be  detected 
in  moles  even  when  blood  has  broken  into  and 
obliterated  the  amniotic  cavity. 

Chorionic  villi,  when  seen  in  sections  of  an  apoplectic 
ovum,  are  very  easily  recognised.  Usually  they  appear 
as  clusters  of  circular  bodies;  ten  or  more  may,  in 
fortunate  sections,  be  counted  together  ;  more  frequently 
they  occur  in  groups  of  three  or   four,  and  often  a  wide 

section  of  clot  may  be 
examined  without  find- 
ing more  than  two  or 
three.  Under  a  low 
power  they  present  an 
external  layer  of  epi- 
)'^g^W:^^^^OT^«  thelial-like  cells,  the 
I  ^^^^^-^^^T^^^^^W^^        central     space     being 

occupied  by  irregular- 
shaped  cells  (Fig.  98). 

Fig.      98.— Microscopical      Appearances  _   of    When  examined  Undcr 
Chorionic    Villi     in      transverse     section.     l-.i"„V.   i-v/-.,Troi-c-     flio  l?i-.-.if 
Low  magnification.  (^^S^  pOWCrS,   tUC  limit- 

ing layer  is  often  formed 
of  a  perfectly  regular  row  of  cubical  epithelium.  Some- 
times the  interior  of  a  villus  resembles  the  stratum  inter- 
medium of  an  enamel  organ.  In  larger  villi  a  double  row 
of  epithelium  may  be.  detected. 

That  these  oval  and  circular  organised  clots  found 
in  Fallopian  tubes  are  impregnated  ova  is  amply  proved 
by  the  fact  that  occasionally  they  contain  embryos.  In 
Herman's  specimen,  referred  to  on  page  367,  the  mass  in 
the  tube  was  a  typical  example  of  an  apoplectic  ovum, 
and  the  amniotic  cavity  was  occupied  by  an  embryo. 


'It' 


Plate  v.— A  T,.-,  -  ATr 


• ;;, ; 


— tvlUCQUS      M  E  MB  RAii  E      .-  >'''/''  /^^ 

nr  P,"  In.   magnification.     The  natural  size 
Fig.  99- 

.•ncn.c  vii.i  are  seen  in  section. 


321 


CHAPTER   XXVIII. 

PRIMARY    RUPTURE    OF    THE    GESTATION    SAC. 

That  the  majority  of  pregnant  Fallopian  tubes  rupture 
is  undeniable.  The  exceptions  are  those  cases  in  which 
the  ovum  is  discharged  through  the  abdominal  ostium 
(tubal  abortion),  or  the  exceedingly  rare  instances  in 
which  the  ovum,  becoming  apoplectic  at  a  very  early 
date,  remains  quiescent  in  the  tube. 

Rupture  of  the  tube  will  be  discussed  in  sections 
indicated  in  the  subjoined  table  : — 
I.  Primary  Rupture. 

{a)  lntra-perito7ieaL 
{b)  Extra-peritoneaJ .    ■ 

11.  Secondary  Rupture. 
{a)  Intra-periioneal. 
(b)  Extra-peritoneal. 

Primary  rupture. — This  term  refers  to  the  rupture 
of  the  tube  which,  in  the  majority  of  cases,  occurs  at 
some  period  between  the  third  and  tenth  week  after 
impregnation,  and  is  rarely  deferred  beyond  the  twelfth 
week. 

The  predisposing  causes  of  rupture  are  the  gradual 
thinning  of  the  walls  of  the  gestation  sac  as  the  embryo 
grows,  and  the  sudden  enlargement  of  the  ovum  by 
haemorrhage-into  its  villi.  Rupture  is  sometimes  induced 
by  violence. 

Before  considering  this  event  in  detail,  we  may  for  a 
moment  study  the  relation  of  the  Fallopian  tube  to  the 
broad  ligament.  The  healthy  tubes  in  the  human  female 
occupy  the  free  borders  of  this   structure,  and  are  on 

.V 


32  2.  Tubal  Pregnancy. 

two-thirds  of  their  circumference  invested  by  it ;  indeed, 
the  tube  is  held  in  position  by  a  peritoneal  investment 
resembhng  the  mesentery.  The  portion  of  the  broad 
Hgament  adjacent  to  the  tube  is  appropriately  termed  the 
mesosalpinx. 

When  the  tube  becomes  enlarged  in  consequence  of 
inflammation,  or  dilated  by  an  embryo  growing  within  its 
lumen,  the  layers  of  the  mesosalpinx  become  separated 
by  the  enlarging  tube. 

This  separation  of  the  layers  of  the  mesosalpinx,  how- 
ever, does  not  occur  along  the  whole  extent  of  the  tube, 
but  is  restricted  mainly  to  its  middle  third.  It  is  im- 
portant to  realise  this,  because  it  explains  the  frequency 
of  inti'a-peritoneal  rupture  when  the  ovum  is  situated  in 
the  outer  third  of  the  tube.  The  anatomical  evidence 
alone  leads  us  to  expect  that  when  a  pregnant  tube 
ruptures  the  chances  of  this  accident  involving  the 
serous  covering  •  would  be  greatly  in  excess  of  rupture 
through  the  uncovered  portion,  and  as  a  matter  of  fact 
intra-peritoneal  is  to  extra-peritoneal  rupture  in  the  pro- 
portion of  three  to  one. 

In  primary  iiitra-peritoiieal  rupUire,  the  ovum, 
accompanied  by  a  variable  amount  of  blood,  may  be  dis- 
charged directly  into  the  peritoneal  cavity.  The  quantity 
of  blood  extravasated  depends  upon  the  date  of  rupture. 
When  it  occurs  early,  the  blood  extravasated  may  amount 
to  a  few  ounces,  but  after  the  first  month  it  is  usually 
very  copious,  and  frequently  causes  death  in  a  few  hours. 
When  rupture  is  deferred  until  the  seventh  week  the 
ovum  is  not  so  constantly  discharged  through  the  rent, 
and  as  the  walls  of  the  gestation  sac  are  prevented 
from  contracting,  the  amount  of  blood  which  escapes  is 
often  very  large. 

When  the  hosmorrhage  is  moderate  in  amount  and 
the  patient  escapes  the  immediate  dangers  incidental  to 


Primary  Rupture.  323 

the  accident,  especially  shock,  the  effused  blood  may 
undergo  partial  absorption,  and  recovery  ensue.  Authentic 
instances  of  this  are  uncommon,  but  satisfactory  evidence 
in  support  of  this  will  be  adduced  in  the  following  chap- 
ters. When  the  amount  of  blood  poured  out  is  large — 
forty  or  more  ounces— there  is  a  certain  amount  of  risk 
of  peritonitis.  It  is,  however,  well  established  that  this 
complication  rarely  causes  death  after  primary  rupture. 

It  has  been  urged  that  primary  intra-peritoneal  rupture 
is  almost  uniformly  fatal  unless  art  intervenes,  but  this 
requires  qualification.  When  the  haemorrhage  is  not 
excessive,  the  blood  collects  in  the  recto-vaginal  pouch 
and  floats  up  the  coils  of  intestines,  and  these,  with  the 
omentum,  gradually  form  a  covering  to  the  fossa  by 
adhering  together,  thus  isolating  the  blood  in  the  pelvis 
from  the  general  peritoneal  cavity.  Unless  hsemorrhage 
recurs  the  fluid  portions  of  the  blood  are  slowly  ab- 
sorbed, and  the  patient  recovers,  but  convalescence 
is  very  tardy. 

The  dangers  of  primary  intra-peritoneal  rupture  are  : — 

1.  Rapid  death  from  haemorrhage. 

2.  A  fatal  result  may  ensue  from  repeated  haemor- 

rhage. 

3.  Peritonitis.     This  is  very  rare. 

Primary  extra-peritoneal  rupture. — In  a  fair 
proportion  of  cases  the  tube  ruptures  through  that  portion 
of  its  circumference  lying  between  the  separated  layers 
of  the  mesosalpinx.  When  this  happens  the  blood  and 
ovum  are  forced  into  the  connective  tissue  between  the 
layers  of  the  broad  ligament.  In  most  cases  this  is 
fortunate  for  the  patient,  as  the  bleeding  becomes  checked 
by  the  pressure  exerted  by  the  resistance  which  occurs 
when  the  mesometric  tissue  becomes  distended,  and  is 
arrested  before  it  assumes  dangerous  proportions.  In 
such  cases  it  is  fortunate  for  the  patient  if  the  ovum  has 
V  2 


324  Tubal  Pregnancy. 

been  converted  into  a  mole,  for  then  the  pregnancy 
is  ended ;  the  blood  and  ovum  are  sepulchred,  as  it 
were,  in  the  mesometrium,  and  rarely  cause  subsequent 
trouble.  . 

Rupture  may  take  place,  and  the  embryo  remain 
uninjured  and  continue  its  development  with  advantage, 
for,  no  longer  confined  within  the  narrow  limits  of  the 
tube,  it  begins  to  avail  itself  of  the  additional  space  thus 
offered,  and  burrows,  as  it  grows,  between  the  layers  of 
the  mesometrium. 

According  to  the  manner  in  which  this  mode  of 
rupture  is  sometimes  described,  it  might  be  imagined 
that  the  tube  splits,  and  the  products  of  gestation  are 
suddenly  discharged  from  the  tube  into  the  broad  liga- 
ment. This  is  not  the  case,  or  the  pregnancy  would  in 
every  instance  come  to  an  end  from  the  dissociation  of 
the  foetal  from  the  maternal  structures.  As  far  as  I  have 
been  able  to  study  the  morbid  anatomy  of  the  accident, 
the  slow  and  gradual  distension  of  the  tube  causes  it  to 
thin  and  gradually  yield  in  that  part  of  its  circumference 
uncovered  by  peritoneum  until  an  opening  forms,  ac- 
companied by  sudden  hsemorrhage,  which  produces 
collapse,  the  profundity  and  duration  of  which  depend 
upon  the  amount  of  blood  that  escapes.  This  artificial 
opening  gradually  extends  until  the  growing  embryo  and 
placenta  make  their  way  into  and  by  degrees  occupy  the 
new  area  of  connective  tissue  opened  up,  unless  the  life 
of  the  embryo  is  endangered  by  renewed  haemorrhage. 

When  pregnancy  continues  in  this  way  it  is  spoken 
of  as  a  "  broad  ligament  gestation,"  because  the  sac  is 
formed  in  part  by  the  expanded  Fallopian  tube  and  the 
layers  of  peritoneum  forming  the  broad  ligament. 

The  development  of  a  foetus  in  this  situation  was 
first  described   by   Dezeimeris,*    in    a  very  inaccessible 

*  Journ.  de  Coiuiaissance  MM.  Chir.,  Jan.,  18 


Extra-Peritoxeal  Rupture.  325 

publication,  as  the  sous-peritone-pelvienne  variety  of 
extra-uterine  gestation.  My  knowledge  of  his  views 
rests  on  the  following  statement  from  Parry's*  book. 

"By  sub-peritoneo-pelvic  (sous-pe'ritone-pelvienne) 
pregnancy  Dezeimeris  intended  to  designate  a  variety  in 
which  the  ovum,  after  quitting  the  ovarian  vesicle,  did 
not  enter  the  Fallopian  tube  nor  fall  into  the  peritoneal 
cavity,  but,  on  the  contrary,  passed  between  the  two 
folds  of  the  broad  ligament,  and  there  developed. 
According  to  this  view,  the  product  of  conception  is 
situated  outside  of  the  cavity  of  the  peritoneum.  That 
the  ovum  has  been  found  in  this  locality  cannot  be 
doubted,  but  when  such  is  the  case  there  is  every 
reason  to  believe  that  it  reaches  this  peculiar  situation 
through  rupture  of  a  tubal  cyst,  in  which  the  integrity  of 
the  peritoneum  was  not  destroyed,  so  that  the  ovum 
escaped  between  the  two  layers  of  the  broad  ligament, 
where  it  continued  to  develop.  It  is  therefore  one  of 
the  terminations  of  an  ordinary  tubal  gestation." 

Subsequent  observation  on  this  head  has  not  only 
justified  Parry's  opinion,  but  demonstrated  the  fact  that 
in  all  tubal  pregnancies  which  survive  the  primary  rupture 
and  continue  their  development,  the  gestation  sac  is 
formed  in  part  by  the  expanded  tube,  but  mainly  by  the 
layers  of  the  corresponding  broad  ligament.  The  proper 
appreciation  of  this  fact  has  done  much  to  simplify  our 
knowledge  of  tubal  pregnancy ;  and  no  one  has  more 
strongly  insisted  upon  its  correctness  than  Law^son  Tait. 

*  Extra-Uterine  Pregnancy,  p.  32. 


326 


CHAPTER    XXIX. 

TUBAL  ABORTION. 

It  has  already  been  pointed  out  that  the  presence  of  an 
impregnated  ovum  in  the  outer  third  of  a  Fallopian  tube 
usually  leads  to  occlusion  of  the  abdominal  ostium ;  this 
event  is  commonly  complete  by  the  end  of  the  sixth 
week,  sometimes  it  is  delayed  to  the  eighth  week ;  it  is 
therefore  a  comparatively  slow  process.  It  is  important 
to  bear  this  in  mind,  because  it  serves  to  explain  an 
apparent  discrepancy,  to  the  effect  that  the  abdominal 
orifice  is  sometimes  open  and  sometimes  closed.  As 
a  matter  of  fact,  the  condition  of  the  ostium  depends 
upon  the  date  at  which  it  is  examined  after  the  lodgment 
of  the  ovum.  So  long  as  this  orifice  remains  open  the 
ovum  is  in  constant  jeopardy  of  being  extruded  through 
it  into  the  peritoneal  cavity,  especially  when  it  lies  in  the 
ampulla  of  the  tube,  and  the  nearer  it  is  situated  to 
the  ostium  the  greater  is  the  chance  of  its  being  thus 
discharged  from  the  tube.  To  this  accident  the  term 
"tubal  abortion"*  may  be  applied,  for  it  is  exactly 
parallel  to  those  early  abortions  occurring  in  connection 
with  uterine  gestation  before  the  end  of  the  second 
month  ;  and  it  further  resembles  them  in  the  fact  that 
the  ovum  is  apoplectic.  These  cases  of  "tubal  abortion" 
are  worthy  of  attention  because  specimens  of  Fallopian 
tubes  have  been  frequently  described  in  which  blood-clot 
has  been  found  hanging  from  their  fringes,   associated 

*  A  term  introduced  by  Keller.    {Zeitsch7'ift  fur  Geburtshiilfe,  Bd. 
xix.  ;  1890.) 


Tubal  Abortion.  327 

with    localised    dilatations    of    the     tubes,    resembling 
gestation  sacs. 

The  term  tubal  abortion  is  applicable  to  cases  in 
which  haemorrhage  takes  place  from  a  gravid  tube,  the 
blood  entering  the  peritoneum  through  an  unclosed 
ostium,  the  tube  remaining  whole  (Fig.  99). 

Many  of  these  cases  resemble  uterine  abortions  in 
which  the  ovum,  from  some  cause  or  other,  becomes 
apoplectic  and  is  expelled,  accompanied  by  a  free  dis- 
charge of  blood  from  the  uterus.  When  it  occurs  early 
the  ovum  is  small,  and,  unless  carefully  sought  for, 
frequently  escapes  detection  ;  when  large,  it  is  easily 
recognised.  In  tubal  abortion  the  same  thing  happens. 
The  ovum  is  discharged  with  a  copious  haemorrhage  into 
the  peritoneal  cavity  through  the  ostium,  accompanied 
with  the  usual  signs  of  internal  bleeding,  and  death  may 
occur  early  from  the  anaemia  thus  induced  or  from  shock. 
Escaping  this  danger,  the  patient  may  fall  a  victim  to 
peritonitis.  In  such  instances  the  ovum,  being  very 
small,  escapes  recognition  when  the  clot  is  examined, 
either  at  the  operation  or  post  mortem.  Tubal  abortion 
can  only  occur  during  the  first  two  months,  for  when  the 
ostium  is  occluded  the  blood  cannot  escape  without 
rupture  of  the  sac.  The  quantity  of  blood  which  flows 
from  the  tube  into  the  peritoneal  cavity  sometimes 
amounts  to  thirty,  or  even  fifty  ounces.  Tubal  abortion 
is  a  subject  of  much  interest,  inasmuch  as  it  furnishes 
many  of  the  cases  of  pelvic  hsematocele  which  are 
ascribed  to  metrorrhagia,  reflux  of  menstrual  blood  from 
the  uterus,  and  haemorrhage  from  the  mucous  membrane 
of  the  Fallopian  tube.  The  reason  for  associating  the 
hsemorrhage  with  metrorrhagia  and  menstruation  is  due 
to  the  fact  that,  whilst  the  ovum  is  growing  in  the.  tube  a 
decidua  is  forming  in  the  uterus.  When  tubal  abor- 
tion   occurs,  haemorrhage   takes   place  from   the  uterus, 


328  Tubal  Pregnancy, 

consequent  on  the  separation  and  expulsion  of  the 
decidua.  Should  this  accident  happen  near  the  time 
the  patient  expects  to  menstruate,  the  case  would  be 
regarded  as  reflux  of  menstrual  fluid  into  the  peritoneum. 
If  it  does  not  coincide  with  a  menstrual  period,  it  is 
then  usually  considered  to  be  of  uterine  origin.  It  will 
therefore  be  well,  in  searching  blood  removed  in  ab- 
dominal operations,  to  examine  carefully  any  apparently 
organised  ovoid  clot,  in  order  to  ascertain  if  it  contain 
an  amniotic  cavity,  with  or  without  an  embryo,  and  also 
ascertain  the  existence  or  otherwise  of  chorionic  villi. 

When  the  ovum  is  lodged  in  the  uterus,  and  haemor- 
rhage indicative  of  abortion  happens,  it  does  not  necessarily 
follow  that  the  ovum  is  immediately  discharged ;  in  some 
instances  it  is  retained  many  days  by  some  portion  of  the 
chorion.  This  is  equally  true  in  tubal  pregnancy.  In  a 
case  of  this  nature,  the  details  of  which  I  communicated 
to  the  Obstetrical  Society,  London,  1890,  a  rounded  body, 
the  size  of  a  cob-nut,  was  found  within  the  tube,  ad- 
herent by  a  narrow  segment  of  its  circumference.  The 
tube  was  full  of  thick  fluid  blood,  and  a  large  quantity 
was  found  free  in  the  peritoneal  cavity ;  this  blood  had 
escaped  from  the  tube,  and  entered  the  peritoneal  cavity 
through  the  unclosed  ostium.  Some  dehcate  processes 
projecting  from  the  small  body  within  the  tube  were 
examined,  and  found  to  be  chorionic  villi.  The  body  and 
the  mucous  membrane  to  which  it  was  attached  were  cut 
out,  embedded,  and  sectioned  for  the  microscope.  It 
then  became  clear  that  it  was  a  small  tubal  mole. 

A  careful  drawing  of  its  microscopical  appearances  is 
furnished  in  Plate  V.  The  clinical  evidence  indicated 
that  the  ovum  had  been  impregnated  three  or  four  weeks. 
This  is  ■  the  smallest  tubal  mole  that  has  come  under  my 
notice. 

Many  of  these  cases  are  overlooked. 


Tubal  Abortion. 


329 


A  glaring  example  of  intellectual  blindness  in  this 
direction  is  furnished  by  Goupil*  in  his  interesting 
account  of  intra-pelvic  haemorrhages  occurring  in  extra- 


CKORIONIC    VILLI 


Fig.    99. — Gravid     Fallopian     lube.      Natural    size.     (From  a  patient  the 
subject  of  tubal  abortion.)    {Trans.  Obstet.  Soc.) 

uterine  pregnancies.     After  arranging  the  various  causes 
of  this  accident  under  five  headings,  he  writes  : — 

''A  sixth  variety  might  have  been  made  in  which 
eifusion  of  blood  results  from  simple  haemorrhage  of  the 
Fallopian  tube,  but  it  would  rest  on  only  one  observation, 


*  Bernutz  and  Goupil :  Clinical  Memoi7-s  on  the  Diseases  of  Women, 
p.  235  ;  New  Sydenham  Society  translation. 


330  Tubal  Pregnancy. 

and  that  an  imperfect  one.  The  foetus  in  that  case  was 
not  found,  and  extra-uterine  pregnancy  was  based  only 
on  the  opinion  of  M.  Robin  that  a  certain  membrane 
presented  the  appearances  of  the  chorion.  M.  Fenerly 
has  pubHshed  the  case  in  his  These  Ifiaiigiirale,  p.  46 
(Paris,  1855).  A  patient  was  admitted  with  sub-acute 
peritonitis,  which  .  terminated  fatally  in  ten  days.  The 
uterine  walls  were  thicker  than  normal.  The  right  Fallo- 
pian tube  contained  a  clot  as  big  as  an  egg,  which  was 
hollow  and  lined  by  a  membrane,  yielding  micro- 
scopically the  characteristics  of  the  chorion.  The 
uterine  cavity  was  lined  with  a  swollen  vascular  mucous 
membrane." 

This  case  was  clearly  a  typical  example  of  an 
apoplectic  ovum  within  the  Fallopian  tube,  and  is  one  of 
the  earliest  examples  I  can  find  recorded,  but  its  true 
nature  was  overlooked. 

Sometimes  they  are  described  by  the  meaningless 
term — haematosalpinx. 

It  is  necessary  to  bear  in  mind  that  in  early  uterine 
abortion,  with  retention  of  an  apoplectic  ovum,  bleeding 
is  apt  to  recur  as  long  as  the  ovum  is  retained ;  so  in  the 
case  of  a  gravid  tube,  as  long  as  the  mole  remains  in  the 
tube  the  hemorrhage  is  almost  sure  to  recur. 

A  correct  appreciation  of  tubal  abortion  is  important 
in  relation  to  pelvic  haematocele,  and  there  can  be  little 
doubt  when  the  condition  is  more  widely  known  it  will 
be  possible  to  formulate  rules  which  will  enable  a  dis- 
■  tinction  to  be  made  between  it  and  primary  rupture  of  a 
gravid  tube. 

Judging  from  descriptions  of  cases  which  have  been 
recently  published,  tubal  abortion  is  a  frequent  termina- 
tion of  tubal  pregnancy  ;  the  occurrence  of  the  accident 
is  indicated  when  a  pelvic  haematocele  forms  gradually  in 
the  course  of  a  few  days.     A  knowledge  of  this  fact  will 


Abortion  into  an  Ovarian  Sac. 


331 


do  much  to  induce  practitioners  to  improve  very  con- 
siderably their  present  unsatisfactory  mode  of  treating 
these  conditions.  For  a  patient  to  be  confined  to  bed  for 
weeks  or  months,  and  afterwards  to  lead  the  life  of  a 
chronic  invalid,  is  a  reproach  to  our  art,  when  by  a  prompt 


FlMBRl/E 


Fig.  100. — Ovarian  Hydrocele. 


operation  the  tube  can  be  removed,  haemorrhage  arrested, 
and  a  speedy  convalescence  ensured. 

In  tubal  abortion  the  blood  extravasated  into  the  peri- 
toneal cavity  is  rarely  found  clotted,  and  it  is  always 
venous  in  character.  The  venous  condition  is  due  to 
the  fact  that  the  oxygen  rapidly  escapes  from  the  blood, 
and  is  absorbed  by  the  surrounding  tissues. 

Tubal  abortion  and  the   ovarian  sac. — The 


332  Tubal  Pregnancy. 

anatomy  of  the  ovarian  sac  has  been  already  discussed  ;. 
for  a  long  time  I  made  many  systematic  observations  of 
the  mammals  in  which  this  sac  is  well  developed,  with 
the  notion  that  an  impregnated  ovum  might  Ije  found 
in  it,  for,  as  far  as  my  investigations  have  extended  into 
the  subject,  I  am  convinced  that  ovariati  gestatioji  has 
no  existence,  but  that  it  may  have  been  mistaken  for 
gestation  in  an  ovarian  sac,  which,  of  course,  is  a  very 
diiferent  matter. 

When  pregnancy  occurs  in  a  Fallopian  tube  the 
ostium  of  which  opens  directly  into  a  complete  ovarian 
sac,  such  as  is  shown  in  Fig.  loo,  it  would  result  that  if 
tubal  abortion  took  place,  the  blood,  instead  of  escaping 
into  the  pelvic  cavity,  would  be  retained  in  the  sac  sur- 
rounding the  ovary,  and  form  what  would  virtually  be  an 
ovarian  haniatocele.  This  would  in  many  cases  be  a 
favourable  termination,  unless  the  haemorrhage  be  so 
profuse  as  to  rupture  the  sac.  In  the  human  subject 
such  a  combination  of  circumstances  must  be  very  rare-  • 


333 


CHAPTER    XXX. 

TUBAL        GESTATION. 
THE    PLACENTA    AND    DECIDUA  ;    SECONDARY    RUPTURE. 

The  placenta  in  tubal  gestation  presents  many  pecu- 
liarities in  its  mode  of  development,  and  is  liable  to  so 
many  vicissitudes  which  influence  very  materially  the 
life  of  the  child,  as  well  as  that  of  the  mother,  and  in 
many  cases  is  such  a  source  of  anxiety  to  the  surgeon, 
that  it  is  imperative  upon  those  who  may  be  called  upon 
to  deal  clinically  with  tubal  gestation  to  consider  the 
subject  with  more  than  ordinary  care. 

It  is  also  necessary  to  consider  it  before  dealing  with 
secondary  rupture  of  the  gestation  sac. 

The  formation  of  the  placenta  in  tnbal  gesta- 
tion differs  in  several  particulars  from  one  developed 
in  the  uterus.  In  normal  gestation  the  uterine  mucous 
membrane  takes  a  large  and  important  share  in  forming 
the  placenta,  but,  as  far  as  I  can  judge  from  my  own 
observations,  the  tubal  mucous  membrane  plays  a  very 
insignificant  part  when  pregnancy  occurs  in  the  tube. 

The  fully-developed  uterine  placenta  is  composed  of 
parts  derived  from  the  maternal  and  foetal  tissues  in 
nearly  equal  parts,  whilst  a  tubal  placenta  is  mainly,  if 
not  entirely,  derived  from  the  foetal  tissues. 

Our  scanty  knowledge  of  the  early  stages  of  the  tubal 
placenta  is  entirely  owing  to  the  difficulty  of  obtaining  spe- 
cimens, because  in  nearly  all  cases  the  tube  has  ruptured, 
and  the  structure  of  the  parts  is  considerably  damaged 
before  they  come  into  the  hands  of  the  histologist. 


334  •  Tubal  Pregnancy. 

Taking  the  generally  received  account  of  the  forma- 
tion of  the  uterine  placenta  as  a  basis  (and  it  should  be 
remembered  that  even  this  is  in  a  large  measure  a  matter 
of  inference),  the  tubal  placenta  develops  in  the  following 
manner : — The  ovum,  soon  after  its  arrest  in  the  tube, 
becomes  shaggy,  from  the  growth  of  chorionic  villi  over 
its  outer  surface.  These  villi  are  at  first  tufts  of  cells 
which  become  vascularised  by  the  entrance  into  them  of 
vessels  derived  from  the  allantois.  As  the  villi  bud  out 
from  the  chorion  they  insinuate  themselves  into  the 
adjacent  folds  of  tubal  mucous  membrane.  As  the  ovum 
increases  in  size,  and  the  tube  slowly  distends,  the  plicae 
of  the  mucous  membrane  become  narrowxd,  but  the 
chorionic  villi  increase  in  length,  thickness,  and  com- 
plexity until  the  tubal  mucous  membrane  is  reduced  to 
extreme  tenuity,  and  its  processes  running  between  the 
villi  are  reduced  to  thin  streaks. 

When  clusters  of  chorionic  villi  are  cut  at  right  angles 
and  examined  under  the  microscope,  they  present  an 
appearance  identical  with  sections  prepared  in  a  similar 
manner  from  a  uterine  placenta  about  the  sixth  or  seventh 
month  of  gestation. 

A  careful  examination  of  several  early  examples  of 
tubal  gestation  has  served  to  convince  me  that  the 
tubal  mucous  membrane  takes  no  share  in  the  formation 
of  the  placenta. 

Thus  the  tube,  when  occupied  by  a  developing  ovum, 
conducts  itself  very  differently  to  a  gravid  uterus.  The 
walls  of  the  uterus  enlarge  uniformly  and  the  mucous 
membrane  thickens.  The  tube,  on  the  contrary,  becomes 
gradually  thinned  and  expanded.  In  some  instances 
there  may  be  a  little  thickening  at  the  placental  site. 

Parry,  in  discussing  this  matter,  writes  : — "  The  mus- 
cular coat  may  be  greatly  thinned  and  atrophied,  so  that 
the  retention  of  the  ovum  in  its  cavity  is  almost  entirely 


The  Dec  id  u  a.  335 

due  to  the  support  of  the  peritoneum.  As  a  rule,  how- 
ever, the  muscular  layer  of  the  tube  is  found  hypertro- 
phied.  Under  the  influence  of  the  stimulus  imparted 
by  the  presence  of  a  vitalised  germ  in  the  cavity  of  the 
organ,  the  muscular  fibres  undergo  hypertrophy,  much  as 
those  of  the  gravid  uterus  do  after  a  normal  conception. 
This  process,  however,  is  less  rapid  and  energetic  than 
it  is  in  the  organ  which  was  specially  intended  for  the 
reception  and  development  of  the  product  of  conceptioti. 
It  cannot  therefore  keep  pace  with  the  increase  in  size  of 
the  ovum,  in  consequence  of  which  the  muscular  coat 
may  present  the  appearance  of  being  thinned  and  atro- 
phied, even  though  the  whole  amount  of  muscular  tissue 
may  be  increased." 

The  decidua. — Concerning  the  decidua,  Parry 
writes: — "The  development  of  the  decidua  in  extra- 
uterine pregnancies  has  given  rise  to  much  discussion. 
Even  at  the  present  time  (1876)  opinions  are  very  varied 
in  regard  to  it,  some  contending  that  it  is  formed  in  all 
cases,  others  that  it  lines  the  extra-uterine  gravid  cyst " 
(p.  68).  He  then  gives  references  to  those  authorities 
who  beUeved  that  the  decidua  always  surrounds  the 
ovum  and  those  who  are  of  opinion  that  it  is  always 
formed  in  the  uterus.  All  recent  writers  who  have 
studied  the  pathology  of  tubal  pregnancy  are  unanimous 
that  no  decidua  forms  in  the  tube.  The  majority  are  of 
opinion  that  it  forms  in  the  uterus  in  all  cases.  My  own 
observations  are  so  thoroughly  consonant  with  Parry's 
that  his  views  will  be  given  in  his  own  words  : — 

1 .  In  all  varieties  of  extra-uterine  pregnancy  a  decidua 

forms  in  the  uterine  cavity,  as  in  normal  gesta- 
tion, but  none  surrounds  the  ovum. 

2.  The  decidua  is  rarely  retained  until  the  completion 

of  gestation,  and  thrown  off  during  false  labour. 
More  frequently,  if  the  patient  goes  to  term,  it  is 


33^^  Tubal  Pregnancy. 

discharged  during  the  early  periods  of  pregnancy 
in  small  fragments,  and  without  producing  pain  ; 
or  else  it  is  expelled  e7i  masse  with  symptoms  of 
miscarriage. 
3.  The  absence  of  a  uterine  decidua  when  death  has 
occurred  from  rupture  of  the  cyst,  even  in  the 
early  stages  of  pregnancy,  is  not  proof  that  the 
membrane  has  not  been  formed,  but  simply  that 
it  has  been  expelled  before  the   death  of  the 
foetus.'^ 
It    is    important   not   to    confound    the    decidua    of 
pregnancy  with  menstrual  decidua  occurring  in  what  is 
called  membranous  dysmenorrhoea. 

Menstrual  decidua  rarely  exceed  an  inch  or  an  inch 
and  a  quarter  in  length,  and  are  scarcely  a  line  in  thick- 
ness. As  a  rule  they  are  translucent,  and  rarely  passed 
entire. 

Decidua  of  p7'egnancy  are  larger,  and  vary  in  thickness 
from  an  eighth  to  a  quarter  of  an  inch.  They  may  be 
described  as  bags  resembling  in  outline  an  isosceles 
triangle.  The  base  corresponds  to  the  fundus  of  the 
uterus,  and  the  apex  to  the  internal  os.  At  each  angle 
of  the  triangle  there  is  an  opening.  Those  at  the  basal 
angles  correspond  to  the  Fallopian  tubes,  and  the  apical 
orifice  to  the  cervical  canal.  The  outer  aspect  is  shagg}', 
and  the  inner  surface  is  dotted  with  the  orifices  of  uterine 
glands  (Griffith). 

Up  to  the  period  of  primary  rupture  the  formation  of 
.the  placenta  has  been  proceeding  in  relation  with  the 
mucous  membrane  of  the  Fallopian  tube,  but  after  this 
event,  if  the  disturbance  of  the  parts  is  not  so  great  as  to 
terminate  the  pregnancy,  the  course  of  events  is  modified 
in  a  remarkable  manner.     We  are  indebted  largely  to  the 

*  Extra-Ufefine  Pregnancy. 


The  Tubal  Placenta.  337 

admirable  investigations  of  Drs.  Berry  Hart  and  Carter 
for  the  facts  upon  which  this  account  is  based.  After 
primary  rupture  of  the  tube,  the  embryo  and  placenta 
(when  the  development  is  sufficiently  advanced)  gradually 
occupy  a  sac  formed  by  the  expanded  tube  and  separated 
layers  of  the  broad  ligament,  the  floor  of  this  space  being 
formed  by  connective  tissue  and  the  levator  ani  muscle. 

The  ultimate  eftects  of  this  gradual  dislocation  of  the 
embryo  and  placenta  depend  mainly  upon  the  original 
position  of  the  placenta.  Dr.  Berry  Hart  points  out  that 
if  the  embryo  lies  above  the  placenta,  the  latter  becomes 
depressed  downwards  between  the  layers  of  the  meso- 
metrium  until  it  is  arrested  by  the  pelvic  floor.  If,  on  the 
contrary,  the  embryo  lies  below  the  placenta,  the  embryo 
in  its  membranes  burrows  between  the  layers  of  the 
mesometrium,  and  the  placenta  becomes  pushed  up  by 
the  growing  embryo  until  it  lies  high  in  the  abdomen. 
He  has  had  opportunities  of  investigating  the  structure  of 
these  extra-uterine  placentae,  and  points  out  that  in  tubal 
gestation  the  villi  lie  embedded  in  decidual  cells,  and  no 
intervillous  sinus  system  seems  to  exist.  Large  sinuses, 
however,  have  formed  in  the  muscular  wall.  The  villi 
are  well-formed,  and  are  covered  with  perfect  epithelium. 
The  decidual  cells  are  large,  and  have  a  large  nucleus  and 
nucleolus.  When  the  placenta  is  displaced  into  the 
mesometric  tissue — and  we  must  bear  in  mind  that  this 
displacement  occurs  gradually — the  placental  structure 
becomes  seriously  damaged.  The  villi  are  less  perfect  in 
contour,  blood  extravasation  is  present,  blood  crystals 
are  abundant,  while  the  decidual  cells  are  few  and  less 
perfect. 

Dr.  Berry  Hart's  observations  lead  him  to  conclude 
that  the  displacement  of  the  placenta  from  mucous  mem- 
brane to  connective  tissue  gradually  reduces  the  placenta 
to  a  mass  of  compressed  villi,  the  serotina  is  destroyed 
w      . 


338 


Tubal  Pregnancy. 


and  replaced  by  blood  crystals  and  organising  blood-clot. 
The  least  damage  is  sustained  by  the  placenta  when  the 
embryo  is  situated  above  it,  because  under  such  condi- 
tions it  undergoes  the  minimum  amount  of  displacement. 


Levator  aai. 


Fig.  loi. — Transverse  Section  of  the  Pelvis  of  a  Woman  with  an  Embryo  and 
Placenta  of  the  fourth  month  of  Gestation  occupying  the  right  Broad 
Ligament.     (After  Berry  Hart.) 

The  extreme  disorganisation  to  which  the  placenta  is 
liable  when  it  forms  the  roof  of  the  gestation  sac  may  be 
studied  even  in  the  early  stage  of  the  pregnancy.  In 
1 89 1  I  exhibited  before  the  Obstetrical  Society*  a  gesta- 
tion sac  which  had  ruptured  at  the  sixth  week  into  the 
mesometrium.  and  at  the  twelfth  week  burst  into  the 


*  Trans.  Obstet.  Soc. ,  London,  vol.  xxxiii,  p.  70, 


Migration  of  the  Placenta.  339 

general  peritoneal  cavity.     A  prompt  operation  saved  the 


Li\er 


Seat  of  Ruptuie 
Blood 

Placenta 
Peritoneum 

Peritoneum 


FogtUb    — 


Bladder 
Rectum 

Vagina 


Fig.  102.— Sagittal  Section  of  a  Cadaver,  with  a  Broad  Ligamen  Pregnancy  at 
term  ;  it  indicates  the  extreme  displacement  of  the  Placenta.  (After  Berry 
xlart.) 

patient's  life.     The  placenta  was  situated  above  the  em- 
bryo, and  repeated  haemorrhages  into  its  substance  had 
w  2 


340  Tubal  Fkegnancv. 

converted  it  almost  entirely  into  a  disc  of  blood-clot,  in 
which,  on  microscopic  examination,  a  few  groups  of  viUi 
could  be  detected. 

The  amount  of  displacement  to  which  the  placenta  is 
liable  when  the  embryo  lies  below  it  is  well  shown  in 
Fig.  I02,  which  was  made  by  Dr.  Berry  Hart  from 
frozen  sections  which  he  prepared  from  a  woman  who 
died  from  secondary  rupture  of  the  gestation  sac. 

In  the  specimen  from  which  Fig.  loi  was  obtained 
the  pregnancy  had  advanced  to  the  fourth  month.  The 
embryo  lies  between  the  layers  of  the  broad  ligament, 
whilst  the  placenta  forms  a  kind  of  roof  to  the  gestation 
sac. 

The  drawing,  Fig.  102,  represents  the  relation  of  parts 
when  such  a  pregnancy  goes  to  term.  The  placenta  has 
been  gradually  elevated  from  the  pelvis  until  it  is  raised 
far  above  the  level  of  the  umbilicus.* 

It  must  be  obvious  that  a  placenta  when  displaced  in 
this  way  must  have  its  function  very  seriously  hampered 
in  comparison  with  one  firmly  deposited  on  the  floor  of 
the  pelvis.  It  has  been  demonstrated  histologically  that 
there  is  great  damage  produced  by  this  slow  migration. 

It  is  of  the  utmost  importance  to  correctly  appreciate 
the  structural  alterations  which  occur  in  the  placenta 
consequent  upon  these  remarkable  displacements  to 
which  it  is  subject,  as  they  exert  a  great  influence  on  the 
subsequent  history  of  the  pregnancy,  greatly  imperilling 
the  life  of  the  mother,  and  being  in  most  cases  disastrous 
to  the  life  of  the  foetus. 

The  danger  in  which  such  displacements  of  the  pla- 
centa place  the  mother  is  this  : — The  constant  tension 
to  which  the  peritoneum   covering  the  gestation  sac   is 

*  These  valuable  observations  were  communicated  to  the  Obstet, 
Society,  Edin.,  1887.  The  paper  is  published  with  admirable  illustra- 
tions in  the  Edin,  Med,  Journ, ,  vol.  xxxiii,  p.  332. 


MlGRAriON  OF    THE    PlACENTA.  34 1 

subject  may  at  any  time  cause  it  to  yield,  and  lead  to 
partial  detachment  of  the  placenta,  and  as  a  consequence 
severe  hemorrhage,  which  may  take  place  into  the  gesta- 
tion sac,  or  more  probably  into  the  peritoneal  cavity. 
Such  haemorrhage  in  the  late  stages  of  these  pregnancies 
is  almost  invariably  fatal.  Indeed,  a  woman  with  a 
broad  ligament  pregnancy,  with  the  placenta  situated 
above  the  foetus,  runs  a  far  greater  risk  of  losing  her  life 
than  if  she  were  the  victim  of  the  dreaded  condition 
termed  plac€7ita  prcEvia, 

Apart  from  this  great  danger,  the  woman  runs  an  in- 
direct risk  through  the  foetus.  The  latter  is  dependent 
upon  the  placenta  exactly  as  in  uterine  gestation.  We 
have  seen  already  that  tubal  placentae  are  less  perfect 
organs  than  uterine  placenta.  Even  when  a  tubal  pla- 
centa lies  below  the  embryo  after  rupture,  its  structure  is 
sufficiently  damaged  to  render  it  an  inefficient  respiratory 
organ  ;  hence  it  must  be  much  less  adequate  for  the  needs 
of  the  foetus  when  it  is  situated  above  the  embryo,  and 
subject  to  the  grievous  vicissitudes  which  have  been 
already  discussed. 

The  results  on  the  embryo  are  very  manifest.  A 
foetus  the  product  of  a  tubal  gestation  is  a  very  unsatis- 
factory individual.  Even  when  rescued  by  the  surgeon 
at  or  near  time,  they  rarely  survive  longer  than  a  few  days 
or  weeks.  In  many  cases  they  are  ill-formed,  and  present 
hydrocephalus,  club-foot,  spina  bifida,  ectopia  of  the 
viscera,  or  similar  deformity,  and  even  when  normal  in 
shape  are  exceedingly  defective  in  size. 

In  the  majority  of  cases  the  foetus  dies.  When  this 
event  occurs  at  the  fourth  or  fifth  month  there  is  reason 
to  believe  that  the  placenta  may  in  some  instances  con- 
tinue to  grow,  instead  of  undergoing  atrophy.  At  any 
rate,  it  is  quite  certain  that  now  and  then,  in  cases  of 
tubal  gestation,  a  shrivelled  foetus  is  found  attached  to  a 


342  Tubal  Pregnancy. 

placenta  which  is  not  only  out  of  relative  proportion  to 
the  foetus,  but  absolutely  larger  than  the  placenta  of  a 
uterine  foetus  at  full  term.  The  death  of  the  foetus  may 
indirectly  affect  the  mother.  As  long  as  the  sac  contain- 
ing the  dead  foetus  remains  air-tight,  it  is  a  safe  place  of 
sepulture,  the  foetus  becoming  desiccated  and  thoroughly 
mununified  in  a  fair  proportion  of  cases  ;  in  others  it 
undergoes  partial  conversion  into  adipoceix  ;  and  in  a  few, 
lime-salts  are  deposited  in  the  walls  of  the  sac  and  super- 
ficial parts  of  the  foetus,  and  convert  it  into  a  litho- 
pcedion. 

More  frequently  gases  from  adherent  bowel  find  their 
way  into  the  sac,  decomposition  ensues,  and  the  gesta- 
tion sac  becomes  converted  into  an  abscess  cavity. 

Under  such  conditions  the  cutaneous  walls  of  the  sac 
may  slough,  and  an  attempt  be  made  to  discharge  the 
foetus  and  placenta,  as  in  the  case  recorded  by  Sheild,*  in 
which  a  young  married  woman  had  been  for  several 
weeks  ill  with  fever,  and  complained  for  several  months 
of  an  abdominal  tumour.  The  uterus  was  explored,  and 
found  to  be  empty.  When  Mr.  Sheild  saw  the  patient 
she  had  a  large  circular  orifice  with  sloughy  margins  in 
the  situation  of  the  umbilicus.  Through  this  a  black, 
pultaceous,  offensive  mass  protruded.  Chloroform  was 
administered,  and  the  protrusion  was  found  to  be  the 
buttocks  of  an  extra-uterine  foetus.  The  opening  was 
enlarged  and  the  foetus  extracted  ;  the  placenta  was  re- 
moved piecemeal.  The  gestation  sac  was  completely 
isolated  from  the  general  peritoneal  cavity.  Cases  in 
which  the  integuments  slough  so  as  to  allow  the  foetus  to 
present  in  this  way  are  very  rare,  and  probably  only  occur 
when  the  peritoneum  is  stripped  from  the  anterior  ab- 
dominal wall  by  the  gradual  growth  of  the  foetus. 

"    Trans.  Obsiet.  Soc,  London,  vol.    xxxiii.  p.  148. 


Secondary  Rupture.  343 

The  changes  which  occur  in  retained  extra-uterine 
foetuses  are  considered  more  fully  in  chapter  xxxiv. 

Secondary  rupture. — When  the  pregnancy  con- 
tinues between  the  layers  of  the  broad  ligament,  the  ges- 
tation sac  may  at  any  moment  rupture,  and  the  risk  of 
this  accident,  as  far  as  can  at  present  be  judged,  is  much 
greater  when  the  placenta  is  situated  above  the  foetus. 
As  the  pregnancy  progresses  the  peritoneum  forming  the 
sac  becomes  stretched  and  stripped  from  adjacent  parts, 
and  from  the  viscera.  Sometimes  as  the  sac  extends  into 
the  abdomen  it  will  strip  the  peritoneum  from  the  anterior 
abdominal  wall,  as  in  the  case  of  an  over-distended 
bladder,  only  to  a  much  greater  extent.  This  fact  was 
absolutely  demonstrated  in  the  specimen  from  which  the 
drawing  (Fig.  102)  was  prepared;  its  clinical  import  is  in- 
dicated in  Sheild's  remarkable  case.  When  the  serous 
membrane  is  stripped  from  the  posterior  aspect  of  the 
pelvis,  the  rectum  may  be  deprived  of  its  serous  invest- 
ment, as  well  as  the  posterior  surface  of  the  uterus^  the 
foetus  and  placenta  insinuating  themselves  between  these 
parts,  beneath  the  peritoneum. 

At  any  period  between  the  twelfth  week  and  term 
the  gradually  thinning  gestation  sac  may  rupture.  The 
effects  of  this  accident  vary.  When  the  rent  involves  the 
placenta,  as  is  almost  certain  when  this  organ  is  situated 
above  the  foetus,  terrible  hsemorrhage  and  a  speedy 
death  are  the  usual  consequence  if  the  gestation  has 
advanced  beyond  the  mid-period  of  pregnancy ;  before 
this  date  the  hcemorrhage  may  not  always  be  so  severe, 
and  will  afford  opportunities  for  surgical  intervention. 
When  the  sac  bursts  into  the  peritoneum  in  this  way  it  is 
spoken  of  as  secondary  intra-peritoneal  rnptnre, 
and  the  anatomical  relations  of  this  form  of  rupture  are 
shown  in  Fig.  102,  with  the  placenta  forming  the  roof  of 
the  gestation  sac. 


344  Tubal  Pregnancy. 

When  the  placenta  occupies  the  pelvis,  and  the  fcetiis 
the  abdominal  portion  of  the  sac,  the  latter  may  become 
so  slowly  thinned  that  at  last  it  yields,  and  the  foetus  is 
set  free  into  the  peritoneal  cavity,  and  disports  itself 
among  the  intestines. 

It  must  be  remembered  that  secondary  rupture  may 
be  indefinitely  delayed,  and  in  some  cases  never  occurs. 
The  patient  goes  to  term,  passes  through  a  spurious 
labour,  the  liquor  amnii  is  absorbed,  the  placenta  dis- 
appears, and  the  existence  of  an  extra-uterine  pregnancy 
never  suspected  until  a  mummified  foetus  or  a  litho- 
psedion  is  discovered  at  the  autopsy. 

Of  the  two  forms  of  secondary  rapture,  the  intra- 
peritoneal variety  may  occur  at  any  date  between  the 
twelfth  week  and  term. 

Seconfllary  extra-peritoaiesaS  raipttire  occurs 
after  the  death  of  the  child,  and  is  in  nearly  every 
case  induced  by  suppuration  of  the  gestation  sac. 

Secondary  intra-peritoneal  rupture  near,  or  at  term 
must  be  discussed  more  fully,  because  it  is  these  cases 
which  tend  to  perpetuate  the  belief  that  impregnated  ova 
may  tumble  into  the  peritoneal  cavity,  and  engraft  them- 
selves upon  the  serous  membrane  and  develop.  A 
critical  inquiry  into  this  matter  has  convinced  me  that 
there  is  no  case  on  record  which  can  be  cited  as  decisive 
proof  of  this  occurrence.  There  is  no  such  condition 
as  a  primary  peritoneal  pregnancy.  AH  forms  of  extra- 
uterine gestation  pass  their  primary  stages  in  the  Fallopian 
tube. 

Lawson  Tait*  suggests  a  modification  of  this  view,  to 
the  effect  that  "what  have  been  called  abdominal  preg- 
nancies are  clearly  exceptional  cases  where  primary  tubal 
rupture  at  the  end  of  the  third  month  has  not  proved 

*  LecHircs  o?i  Ectopic  Gestation,  p.  13  ;    1888. 


So-called  Abdominal  Pregnancy.  345 

fatal ;  where  the  extruded  placenta  has  made  for  itself 
visceral  attachments  wherever  it  has  touched ;  or  where 
secondary  rupture  of  a  broad  ligament  cyst  has  converted 
an  extra-peritoneal  ectopic  gestation  into  one  within  the 
peritoneal  cavity." 

This  view  I  cannot  bring  myself  to  accept.  I  am  of 
opinion  that  these  so-called  abdominal  pregnancies  are 
primary  tubal  ;  gradually  the  tube  opens  out  into  the 
broad  ligament,  and  as  it  progresses  to  term  the  walls  of 
the  gestation  sac  rupture,  and  the  foetus  escapes  into  the 
peritoneal  cavity,  as  in  the  remarkable  case  recorded  by 
Jessop  : — ^ 

A  woman  twenty-six  years  of  age  believed  herself  two 
months  pregnant ;  she  was  suddenly  seized  with  violent 
pain  in  the  right  side  of  the  belly,  which  caused  her  to 
faint.  From  the  effects  of  this  trouble  she  kept  her  bed 
two  months.  Five  months  later,  at  a  consultation,  it  was 
decided  that  she  was  a  victim  of  extra-uterine  gestation^ 
and  she  was  admitted  into  the  Leeds  Infirmary.  As  the 
woman  was  in  a  critical  condition,  abdominal  section  was 
performed  without  delay.  On  cutting  through  the  anterior 
wall  of  the  belly,  the  breech  and  back  of  a  child  thickly 
coated  with  vernix  caseosa  came  into  view.  The  child 
had  lodged  in  the  midst  of  the  bowels,  free  in  the  cavity 
of  the  abdomen.  No  trace  of  cyst  or  membrane  could 
be  discovered.  The  placenta  was  seen  covering  the  inlet 
of  the  pelvis,  like  the  lid  of  the  pot,  and  extending  some 
distance  posteriorly  above  the  brim,  where  it  apparently 
had  an  attachment  to  the  large  bowel  and  posterior  ab- 
dominal wall. 

The  patient  recovered  from  the  operation,  and  the 
child  lived  for  eleven  months. 

From  this  case  nothing  positive  can  be  inferred,  as 

*    Trans.  Ohstet.  Soc,  London,  vol.  xviii.  p.  261. 


34<5  Tubal  Pregnancy. 

fortunately  the  woman  recovered,  therefore  the  relation 
of  the  placenta  to  the  gestation  sac  and  the  condition 
of  the  Fallopian  tubes  could  not  be  ascertained. 

Champneys*  has  described  a  similar  case  with  great 
care.  The  patient  was  admitted  into  St.  George's  Hos- 
pital with  well-marked  symptoms  of  extra-uterine  gestation. 
In  June,  1886,  she  was  seized  with  sudden  cramp-like 
pain  in  the  left  iliac  fossa,  and  was  confined  to  bed  for  a 
week.  Her  medical  attendant  detected  a  swelling  in  the 
right  iliac  fossa.  From  that  time  until  October  she 
suffered  constant  cramp-like  pains  in  the  left  iliac  fossa,  and 
at  this  date  her  condition  became  so  serious  that  she 
sought  admission  into  the  hospital,  and  physical  examina- 
tion made  it  clear  that  she  was  the  victim  of  extra- 
uterine gestation,  which  had  advanced  to  the  seventh 
month.  Operative  interference  was  advised.  When  the 
abdominal  walls  were  divided  the  buttocks  of  the  foetus 
were  reached.  The  report  then  continues  : — "  No  sac 
was  seen  over  them ;  the  layer  immediately  covering  the 
foetus  was  a  dull  white  membrane.  Almost  at  once,  on 
exposing  the  foetus,  a  coil  of  pink  healthy  small  intestine 
rolled  over  it  from  the  right  side.  The  foetus  was  free  in 
the  abdominal  cavity.  No  liquor  amnii  was  seen. 
The  foetus  was  lying  head  downwards  in  the  left  iliac 
fossa,  with  occiput  posterior  and  to  the  left  side.  The 
feet  were  sought,  and  it  was  extracted  by  them — the  face 
being  born  before  the  occiput.  The  patient  died  on  the 
thirty-second  day  after  the  operation.  At  \\\^  post  vwrtem 
the  placenta  was  found  lying  above  the  pubes,  loose  in  a 
sac  formed  of  false  membrane,  bounded  above  by  the 
displaced  transverse  colon,  in  front  and  below  by  the 
omentum.  The  sac  wall  varied  in  thickness  from  ~jr  to  -g- 
of  an  inch.     The  pelvic  organs  were  so  matted  together 

*   Trans.  Ohstcf.  Sor.,  Loudon,  vol.  xxix.  p.  456. 


So-called  Abdominal  Pregnancy.  347 

that  the  relation  of  parts  could  not  satisfactorily  be  made 
out,  but  the  left  tube  could  be  seen  in  its  whole  extent 
apparently  unaltered.  The  relations  of  the  right  tube  to 
the  sac  could  not  be  made  out." 

It  is  also  interesting  to  notice  that  in  discussing  some 
points  in  connection  with  a  similar  case  recently  reported 
by  Mr.  Taylor,*  Dr.  Champneys  expresses  an  opinion 
that  Taylor's  and  Jessop's  cases,  as  well  as  his  own, 
"  might  have  been  tubal  or  tubo-ovarian." 

I  have  had  one  excellent  opportunity  of  dissecting  the 
pelvis  from  a  woman  who  died  after  the  removal  of  an 
extra-uterine  foetus,  which  had  escaped  from  the  gestation 
sac  among  the  intestines.  I  was  able  to  isolate  the  dis- 
placed layers  of  the  right  broad  ligament  forming  the 
gestation  sac,  in  which  a  large  piece  of  amnion  was  re- 
tained. The  placenta  had  occupied  the  pelvis  and  part 
of  the  posterior  wall  of  the  uterus,  beneath  the  peritoneum. 
The  corresponding  tube  and  ovary  were  not  detected. 

The  age  of  the  foetus  and  circumstances  of  the  case 
were  on  all  fours  with  the  cases  of  Jessop,  Champneys, 
and  Taylor. 

^'    Trajis.  Ohstet.  Sue,  London,  vol.  xxxiii.  p.  115. 


348 


CHAPTER    XXXI. 

TUBO-UTERINE      GESTATION. 

When  a  fertilised  ovum  lodges  in  the  section  of  the 
Fallopian  tube  which  traverses  tlie  uterine  wall,  it  is 
termed  tuho-uterine  gestation.  This  variety  runs  a  some- 
what different  course  to  the  purely  tubal  form. 

Tubo-uterine  gestation  is  somewhat  rare ;  many  speci- 
mens described  as  belonging  to  this  class  turn  out  on 
critical  examination  to  be  specimens  of  cornual  preg- 
nancy. 

Dr.  Robert  Barnes*  discusses  interstitial,  or  intra- 
mural, and  cornual  pregnancy  together,  and  writes  : — "  It 
is  convenient  to  discuss  these  conditions  together. 
They  approach  each  other  so  nearly  in  locality  and  other 
characters  that  they  hardly  admit  of  distinct  clinical 
demonstration."  The  occurrence  of  tubo-uterine  gesta- 
tion admits  of  no  doubt  whatever,  and,  fortunately,  a  few 
specimens  exist  of  this  accident  which  demonstrate  its 
absolute  independence  of  cornual  pregnancy.  Two 
specimens,  one  preserved  in  the  museum  of  Guy's 
Hospital,  and  the  other,  which  has  had  the  advantage  of 
careful  investigation  by  Doran,  in  the  museum  of  the 
Royal  College  of  Surgeons,  are  the  most  satisfactory  and 
easily  accessible  examples  in  London. 

The  specimen  at  Guy's  is  described  in  the  Reports 
of  that  hospital  for  i860  by  Dr.  Braxton  Hicks.  The 
dissection  is  thus  recorded  : — "  Uterus  enlarged  to  six 
inches  long,  and  three  and  a  half  to  four  inches  in  diameter 

*  Clinical  Lectiires  ofi  the  Diseases  of  Women,  p.  444  ;  1873. 


TUBO-  UTER INE    GeS  TA  '1  '10 lY. 


349 


at  the  widest  part.  A  ragged  rupture  appeared  on  the 
fundus,  rather  towards  the  left  side,  from  which  blood 
had  poured.  The  uterine  walls  had  increased  in  thick- 
ness to  about  an  inch  and  one-eighth  at  the  widest  part. 


Fig.  103.— Tubo-uterine  Pregnancy.     (Museum,  Guy's  Hospital.) 

"  A  cavity  about  three  inches  in  diameter  (when  col- 
lapsed) was  situated  in  the  substance  of  the  wall  of  the 
fundus,  adjoining  the  left  Fallopian  tube.  This  cavity 
had  extended  the  walls  externally  so  as  to  be  apparent 
there,  and  had  also  encroached  on  the  cavity  of  the 
uterus,  on  the  left  side  of  the  fundus.  The  walls  of  the 
cavity  all  round  were  formed  of  uterine  tissue.     The  wall 


35©  Tubal  Pregnancy. 

separating  it  from  the  uterine  cavity  was  about  one-sixth 
of  an  inch  in  thickness.  An  examination  of  the  specimen 
shows  that  the  cavity  of  the  gestation  sac  is  directly  con- 
tinuous with  the  tube.  The  waUs  of  the  sac  bulge  into 
the  uterine  cavity,  which  is  lined  by  thick  decidua" 
(Fig.  103). 

In  Doran's  specimen  the  uterus  was  five  inches  long 
from  the  fundus  to  the  external  os,  and  appears  unsym- 
metrical,  on  account  of  the  bulging  of  the  cyst  at  its  right 
upper  corner.  The  uterine  cavity  was  lined  with 
d^cidua. 

The  right  side  of  the  fundus  is  dilated,  and  rent 
asunder  by  a  long  ragged  aperture  measuring  two  and  a 
half  inches  when  unstretched.  The  cavity  thus  exposed 
measures  one  inch  and  a  half  vertically,  supposing  the 
edges  of  the  rent  to  be  closed,  and  one  inch  antero- 
posteriorly.  The  walls  are  very  thin  along  the  line  ot 
laceration. 

Anteriorly,  the  round  ligament  springs  from  the  outer 
aspect  of  the  exposed  cavity,  which  bulges  freely,  at  its 
lower  aspect,  into  the  .upper  part  of  the  interior  of  the 
uterus ;  at  this  part  its  walls  are  much  thicker  than 
above.  The  inner  wall  of  the  cyst  is  very  rough,  re- 
sembling to  a  certain  extent  an  auricular  appendix. 
From  some  of  its  numerous  pits  or  depressions  hang 
broken-off  tags  of  chorion,  but  there  is  not  a  trace  of  a 
distinct  decidua. 

The  right  Fallopian  tube  passes  into  the  outer  and 
anterior  aspect  of  the  walls  of  the  cyst,  expanding 
slightly  into  a  funnel-shaped  orifice,  which  opens  into  the 
cavity  of  the  cyst,  close  to  the  rent  in  its  walls.  A  stout 
bristle  introduced  into  the  tube  from  without  passes 
readily  into  the  cavity  through  the  funnel-shaped  orifice, 
which  is  lined  with  very  smooth  mucous  membrane.  On 
the  outer  surface  of  the  portion  of  the  cyst  that  projects 


TUBO-  UTER INE    GeS  TA  TIOX. 


351 


into  the  uterine  cavity  is  another  funnel-shaped  aperture 
with  a  smooth  hning.  A  bristle  passed  from  without, 
througli  this  opening,  enters  the  cavity  of  tlie  cyst  without 


GESTATION     SAC 


CAVITY 
OF     UTCRUS 


Fig.  104.— Tubo-uterine  Pregnancy  :  the  Gestation  Sac  ruptured  at  the  month 
(Museum,  Royal  College  of  Surgeons.) 

the  slightest  obstruction.  There  is  no  evidence  of  rup- 
ture of  the  wall  of  the  uterus  out  of  the  line  of  the  tube, 
as  it  runs  through  the  uterine  tissue  into  the  uterine 
cavity.  Still  less  is  there  any  ground  for  believing  in  a 
partially  bicornuate  condition  of  the  uterus  (Fig.  104). 

This  uterus  was  obtained  from  a  woman  aged  thirty-two 
years  :  she  died  in  about  ten  hours  after  rupture  of  the 


352  Tubal  Pregnancy. 

cyst.  An  embryo,  enveloped  in  membranes,  and  corre- 
sponding to  the  second  month  of  development,  was  found 
floating  in  blood  in  the  abdominal  cavity. 

Tubo-uterine  gestation  differs  in  its  course,  anatomy, 
and  modes  of  termination  from  the  purely  tubal  form.  In 
dealing  with  the  anatomy  of  a  gravid  tube,  it  was  pointed 
oat  that  as  the  gestation  sac  enlarged  its  walls  became 
thinned ;  in  the  tubo-uterine  variety  the  walls  of  the 
gestation  sac  become  greatly  thickened,  and  this  thicken- 
ing extends  to  and  involves  the  uterus.  This  hypertrophic 
condition  of  the  walls  of  the  sac  explains  the  circumstance 
that  whilst  in  the  purely  tubal  form  the  sac  ruptures  very 
early, — usually  about  the  eighth  week,  and  never  deferred 
beyond  the  twelfth — in  the  tubo-uterine  variety  it  may  be 
delayed  much  beyond  this  date. 

The  date  of  rupture  in  three  carefully  authenticated 
cases  is  given  in  the  subjoined  table  : — 

Braxton  Hicks*  The  development  had  probably  proceeded  to 

the  end  of  the  fourth  month. 

Lawson  Taitt  The    patient    thought   she    had    turned    the 

fourth  month. 

DoranJ  About  the  end  of  the  second  month. 

The  sac  of  a  tubo-uterine  gestation  may  rupture  in 
two  directions.  It  may  burst  into  the  peritoneal  cavity, 
and  be  rapidly  fatal,  or  into  the  uterine  cavity,  and  be  dis- 
charged like  an  ordinary  uterine  conception.  It  is  also 
an  important  fact  to  bear  in  mind  that  in  this  variety  the 
sac  does  not  rupture  in  such  a  way  as  to  allow  of  the  em- 
bryo being  dislocated  between  the  layers  of  the  meso- 
metrium. 

An  examination  of  the  clinical  details    of  cases    of 


*  Guy  s  Hospital  Reports,  series  iii.  vol.  vi.  p.  275 

f  Ectopic  Pregnancy,  p.  46. 

X  Trans.  Obstet,  Sue,  London,  vol.  xxiv.  p.  227. 


TUBO-  U  TER IXE    GeS  TA  TION. 


353 


undoubted  tubo-uterine  gestation  indicates  that  intra-peri- 
toneal  rupture  of  the  sac  is  more  rapidly  fatal  than  the 
tubal  form,  and  this  is  due  to  the  greater  amount  of 
haemorrhage,  because  not  only  are  the  walls  of  the  gesta- 
tion sac  thicker,  but  the  rent  often  extends  to,  and  even 
involves  the  uterine  wall. 

As  a  means  of  ready  reference,  the  points  in  which 
the  two  varieties  of  tubal  gestation  differ  from  each  other 


are  arranged  in  tabular  form  : — 


Frequency. 
Gestation  sac. 
Termination. 


Date  of  rup- 
ture or  aboi-- 
tion. 


TUBAL. 

Very  common. 
Walls  are  very  thin. 
{a)  Intra-peritoneal  rup- 
ture. 

[b)  May  rupture  into  the 

mesometric  space. 

[c]  May  abort. 

At  any  date  from  the 
3rcl  to  1 2th  week. 


TUBO-UTERINE. 

Very  rare. 

Walls  very  thick. 
[a]  Intra-peritoneal  rup- 
ture. 
{b)   May      rupture      into 
uterine  cavity,  and  be 
discharged    through 
■vagina. 
At  any  date  from  the 
8th  to  the  20th  week. 


354 


CHAPTER      XXXII. 

CORNUAL  PREGNANCY. 

Since  Kussmaul  demonstrated  beyond  dispute  that  many 
cases  of  supposed  tubal  gestation  were  really  examples  of 
pregnancy  in  a  rudimentary  cornu  of  a  bi-horned  uterus, 
the  subject  has  been  carefully  studied,  and  many  descrip- 
tions of  this  accident  have  been  placed  on  record. 

In  order  to  comprehend  clearly  the  significance  of  bi- 
cornuate  uteri,  we  must  briefly  consider  the  development 
of  the  uterus. 

In  the  mammalian  embryo,  at  a  very  early  date,  two 
longitudinal  tubes,  known  as  Mliller's  ducts,  he  on  the 
dorsal  wall  of  the  abdomen.  Each  duct  opens  anteriorly 
into  the  peritoneal  cavity,  and  posteriorly  into  the  cloaca. 
These  represent  the  oviducts  of  many  fish,  all  reptiles,  and 
birds.  In  the.  male  they  usually  atrophy,  and  only 
vestiges  of  them  persist  in  the  adult.  In  the  human 
female  these  ducts  approach  each  other,  and  coalesce  in 
their  posterior  two-thirds.  For  a  time  the  cavities  remain 
distinct,  but  gradually  the  septum  atrophies  and  leaves  a 
median  chamber,  which  communicates  with  the  peritoneal 
cavity  by  two  narrow  ducts — the  Fallopian  tubes — and 
opens  into  the  vagina  by  a  single  passage,  called  the 
cervical  canal.  The  median  chamber  is  known  as  the 
uterine  cavity. 

During  embryonic  life  the  development  of  the  uterus 
may  be  arrested  in  a  variety  of  ways,  and  give  rise  to 
malformations  of  great  practical  interest. 

The  ducts  may  coalesce,   but  fail  to  communicate; 


Unicorn  Uterus,  355  ' 

each  growing  equally  will  produce  what  is  termed  a 
double  uterus  and  vagina.  This  variety  is  termed  tUeriis 
duplex  hicornis.  In  this  form  of  uterus  the  recto-vaginal 
pouch  is  divided  by  a  median  fold  of  peritoneum  into  a 
right  and  a  left  recess.  In  some  specimens  the  fold  will 
pass  between  the  two  lialves  of  the  uterus,  and  divide 
the  utero-vesical  pouch. 

In  order  to  produce  a  normal  uterus,  the  two 
IMiillerian  ducts  should  be  equally  and  fully  developed. 
In  some  individuals  one  duct  grows  at  a  proper  rate, 
whilst  its  fellow  remains  stunted,  producing  an  unicorn 
uterus. 

Unicorn  uteri  differ  much  in  the  degree  to  which  the 
rudimentary  cornu  is  developed.  They  are  all  similar  in 
having  the  miniature  cornu  attached  to  its  fully-developed 
fellow  near  the  upper  end  of  the  cervix,  and  in  the 
peculiar  shape  of  the  ovary  which  is  attached  to  the 
diminutive  cornu,  for  it  is  elongated,  and  resembles  in 
shape  a  gherkin.  The  thickest  part  of  these  rudimentary 
cornua  is  near  the  attachment  of  the  round  ligament. 

It  would  be  far  beyond  the  scope  of  this  little  work 
to  describe  the  morphology,  pathology,  and  clinical  im- 
port of  malformed  uteri :  but  the  subject  of  tubal  preg- 
nancy cannot  be  discussed  without  some  reference  to 
cornual  pregnancy,  especially  those  cases  in  which  it 
occurs  in  a  rudimentary  cornu.  A  full  discussion  of  the 
subject  would  demand  much  time  and  space. 

When  pregnancy  takes  place  in  one  horn  of  a  well- 
formed  bicornuate  uterus  it  goes  on  to  full  term,  and  ends 
as  happily  as  if  the  organ  were  of  normal  shape.  When 
one  horn  only  is  gravid — and  this  is  the  usual  thing — 
the  non-gravid  half  becomes  much  enlarged ;  in  this  it 
resembles  the  increase  in  size  of  the  uterus  when  the 
Fallopian  tube  is  occupied  by  a  developing  ovum,  but 
there  is  this  difference : — In  tubal  pregnajicy  a  decidual 
X  2 


356 


Tubal  Pregnancy. 


memhrane  forms,  not  in  the  tube,   but  in  the  uterus;  in 


bicornuate  titeri  the  decidua  is  formed  in  the  impregnated 
cornu.     There   is  reason  to  believe  that  a  decidua  forms 


CoRNUAL  Pregnancy.  357 

in  the  unimpregnated  cornu,  but  this  requires  closer  in- 
vestigation than  it  has  yet  received  in  order  to  absolutely 
exclude  the  possibiHty  of  twin  pregnancy. 

The  enlargement  of  both  cornua  when  only  one  is 
impregnated  is  well  shown  in  Fig.  105,  from  a  specimen 
described  by  Dr.  Handheld  Jones.  The  same  condition 
may  be  studied  in  those  mammals  normally  furnished 
with  bi-horned  uteri. 

Gestation  in  such  uteri  is  rarely  a  source  of  trouble, 
but  when  an  impregnated  ovum  is  lodged  in  the  rudi- 
mentary cornu  of  an  u?iicor}i  icterus  it  is  often  attended 
with  disastrous  consequences  to  the  individual. 

Kussmaul,  in  his  classical  work  on  Malfor7iiations  of 
the  Uterus  (1859),  collected  thirteen  cases  of  what  he 
regarded  as  pregnancies  in  the  rudimentary  cornua  of 
unicorn  uteri.  In  a  few  of  the  cases  the  original  authors 
had  recognised  the  nature  of  the  specimens,  but  the 
majority  had  been  reported  as  tubal  pregnancies. 

Since  the  publication  of  Kussmaul's  book  a  few 
examples  of  this  condition  have  been  placed  on  record. 
Of  these,  the  most  carefully  described  are  those  reported 
by  Virchow,  Luschka,  and  Professor  Sir  William  Turner. 

Virchow's  case  is  of  importance,  because  he  points 
out  a  useful  means  of  distinguishing  between  a  tubal 
pregnancy  and  gestation  in  a  rudimentary  uterine  cornu, 
in  regard  to  the  insertion  of  the  round  ligament.  The 
rules  may  be  summarised  thus  : — 

1.  In    a  normal  uterus    the  round  ligajnent   springs 

from  the  upper  angle,  immediately  in  front  of 
the  tube. 

2.  In  tubal  gestatiofi  the  round  ligame?it  is  attached 

to  the  body  of  the  uterus,  on  the  uterine  side 
of  the  gestation  sac. 

3.  In  cor jiual pregnancy  the  round  ligame7it  is  situated 

on  the  outer  side  of  the  gestation  sac. 


35^ 


Tubal  Pregnancy. 


Turner's  specimens  are  interesting  in  relation  to 
these  points.  The  first  consisted  of  the  uterus  and 
appendages  which  were  obtained  fi-om  a  woman  aged 
twenty  years,  who  had  died  with  all  the  signs  characteristic 
of  a  tubal  gestation  which  had  ruptured.  The  parts  were 
sent  originally  to  Sir  James  Simpson,  who  placed  them  in 
Turner's  hands  for  dissection.     The  latter  soon  came  to 


Fig.  io6. — Pregnancy  in  a  Rudimentary  Uterine  Cornu.     (After  Turner.) 
V,  Vagina;  B,  bladder;  O,  ovary;  T,  tube;  L,  round  ligament ;  S,  gestation  sac ; 

P,  pedicle. 


the  conclusion  that  he  had  to  deal  with  pregnancy  in  a 
bicornuate  uterus.  Fortunately,  the  description  is  ren- 
dered clear  by  a  good  drawing  (Fig.  io6).  Connected 
with  the  vagina  was  the  cervix  uteri,  which  communicated 
with  the  right  cornu  of  the  uterus.  This  cornu  was 
inclined  obliquely  upwards  and  to  the  right,  and  termi- 
nated in  a  rounded  end.  It  was  invested  by  peritoneum 
in  front,  behind,  and  to  the  left  side ;  on  the  right  side 
this  membrane  formed  the  folds  of  a  right  mesometrium. 
The  length  of  the  cornu  from  the  external  os  to  the 
cornual  apex  was    lo  cm.,  and  its  greatest  width  5  cm. 


CoRNUAL  Pregnancy.  359 

The  right  round  ligament,  Fallopian  tube,  and  ovary,  with 
its  ligament,  were  attached  to  the  summit  of  this  cornu, 
and  had  the  same  relation  to  each  other  as  in  a  normal 
uterus. 

The  Fallopian  tube,  with  its  fimbriae,  was  1 2  cm.  long. 
The  parovarium  could  be  made  out  in  the  mesosalpinx. 
The  walls  were  thicker  than  in  a  normal  uterus,  and  the 
cavity  contained  a  thick  firm  decidua,  but  no  'fcetus ; 
the  cervical  canal  was  occupied  with  a  mucous  plug. 

Springing  almost  -at  a  right  angle  from  the  left  side 
of  the  right  cornu,  close  to  its  junction  with  the  cervix, 
was  a  flattened  band  which  served  as  a  pedicle  of 
attachment  for  the  left  cornu.  This  pedicle  extended 
upwards  for  3  cm.,  and  then  expanded  into  the  dilated 
portion  of  the  left  uterine  cornu.  The  pedicle  w^as 
invested  with  peritoneum,  and  consisted  of  muscular 
fasciculi,  arteries,  and  veins.  The  horn  was  pyriform  in 
shape,  and  its  greatest  circumference  was  23  cm.  Along 
its  outer  and  posterior  part  there  was  a  rupture  8  cm. 
long,  through  which  a  foetus  and  its  membranes  were 
extruded.  To  the  apex  of  this  horn  the  round  ligament. 
Fallopian  tube,  ovarian  Hgament,  and  ovary  were  attached. 
The  Fallopian  tube  was  12  cm.  long,  including  the 
fimbriae ;  air  blown  into  the  tube  entered  the  cornu. 
The  parovarium  occupied  the  mesosalpinx,  and  one  of 
its  tubules  was  dilated  into  a  cyst  the  size  of  a  hazel- 
nut. The  ovary  contained  a  corpus  luteum.  The  round 
ligament  was  expanded  at  its  origin,  and  extended  from 
close  to  the  Fallopian  tube  down  to  the  pedicle.  The 
wall  of  the  cornu  was  muscular,  like  that  of  a  pregnant 
uterus.  The  pedicle  was  most  minutely  examined  to 
see  if  any  canal  connecting  the  cavity  of  the  impregnated 
horn  with  that  of  the  right  horn,  or  the  cervix  or  vagina, 
could  be  seen.  No  orifice  was  detected  in  or  at  either 
end  of  the  pedicle. 


J 


60  Tubal  Pregnancy. 


This  specimen  bears  out  Virchow's  rules  regarding 
the  relations  of  the  round  ligaments  and  Fallopian 
tubes. 

That  the  tests  founded  on  the  relation  of  the  round 
ligament  to  the  gestation  sac  are  very  useful  is  well 
shown  in  the  second  case  described  in  Turner's  paper. 
After  making  out  the  nature  of  the  first  case,  he 
obtained  Simpson's  permission  to  examine  other  ex- 
amples of  supposed  tubal  pregnancies  contained  in  his 
collection ;  among  them  he  found  the  following  speci- 
men :— 

The  parts  included  an  empty  uterus,  with  its  append- 
ages, taken  from  the  body  of  a  married  woman  thirty-five 
years  of  age,  by  Dr.  Scott,  of  Dumfries,  and  sent  to  Sir 
James  Simpson.  Six  months  before  her  death  the  woman, 
supposed  to  be  pregnant,  was  seized  with  labour  pains, 
which  continued  for  several  days.  These  pains  subsided; 
the  patient  subsequently  went  about  as  usual,  and  the 
swelling  of  the  abdomen  gradually  subsided  to  about 
one-third  the  size  it  was  at  the  time  of  the  unavailing 
labour.      Six  months  later  she  died  from  phthisis. 

The  preparation,  when  it  came  into  Turner's  hands, 
had  been  lying  a  long  time  in  spirit.  He  found  a  large 
irregular  ovoid  sac  68  cm.  in  circumference,  containing  a 
male  foetus  at  apparently  the  full  time  attached  by  a 
funis,  30  cm,  long,  to  a  shrivelled  placenta  connected 
with  the  inner  surface  of  the  sac.  The  gestation  sac  was 
affixed  by  a  pedicle  to  the  cervix  uteri.  On  examining 
the  other  parts  of  the  specimen,  the  upper  part  of  the 
vagina  was  recognised  with  a  cervix  uteri  projecting  into 
it  in  the  usual  manner.  The  cervix  was  continuous  with 
a  right  uterine  cornu.  The  cavity  of  the  cornu  formed 
with  the  cervical  canal  an  obtuse  angle.  The  cornual 
cavity  led  into  the  right  Fallopian  tube.  The  tube  was 
6  cm.  in  length. 


Transmigration  of  the  Ovum.  361 

The  gestation  sac  was  connected  to  the  left  side  of 
the  cervix  by  a  strong  muscular  pedicle,  5  cm.  in  length 
and  2  cm.  in  width.  Standing  from  the  wall  of  the  sac 
were  the  Fallopian  tube  and  round  ligament.  The  tube 
was  13  cm.  in  length,  and  a  fine  probe  could  be  passed 
from  its  abdominal  ostium  to  the  sac  wall.  The  round 
ligament  arose  from  the  sac  wall  anterior  to  the  tube. 
The  ovary  was  flattened,  and  the  mesosalpinx  contained 
a  parovarium.  No  communication  could  be  made  out 
connecting  the  gestation  sac  with  the  vagina,  cervical 
canal,  or  right  uterine  cornu. 

The  contents  of  the  gestation  sac  presented  the 
following  characters  : — 

Large  tracts  of  the  foetal  tissue  had  been  destroyed ; 
in  the  dorsal  region  a  large  patch  of  skin  with  the  sub- 
jacent muscles  had  disappeared ;  the  ribs  and  laminae  of 
the  vertebrae  were  exposed. 

The  placenta  was  tough  and  shrivelled.  The  walls 
of  the  sac  were  thin ;  in  places  the  muscle  fibres  had 
disappeared,  and  large  calcareous  plates  were  distributed 
over  its  inner  wall. 

The  imperforate  condition  of  the  pedicle  in  specimens 
of  this  kind  has  led  to  a  good  deal  of  vague  speculation 
as  to  how  the  contained  ova  became  fecundated.  To 
explain  it  the  theory  known  as  the  "transmigration  of 
the  ovum  "  was  advanced.  It  is  unsupported  by  facts, 
and  quite  unnecessary,  for  we  may  take  it  for  granted 
that  the  channel  of  communication  between  the  rudi- 
mentary cornu  and  cervical  canal  becomes  occluded 
subsequent  to  impregnation. 

The  specimens  of  pregnancy  in  rudimentary  uterine 
cornua  just  considered  illustrate  very  w^ell  tw^o  of  the 
points  in  which  this  abnonnal  form  of  pregnancy  differs 
from  tubal  gestation.  In  the  latter  form  the  tube  always 
ruptures    before    the   twelfth   week,  whereas    in    cornual 


362  Tubal  Pregnancy. 

pregnancy  the  gestation  may  go  on  to  full  term,  and  then 
ineffectual  labour  leads  to  the  death  and  subsequent 
mummification  of  the  foetus ;  or  the  gestation  sac  may 
rupture  at  any  period  from  the  second  to  the  ninth 
month. 

There  is  reason  to  believe  that  a  gravid  uterine  cornu 
may,  in  the  human  subject,  undergo  axial  rotation.  The 
accident  is  fairly  common  in  the  lower  mammals. 

It  has  been  stated  by  writers  on  cornual  pregnancy 
that  the  corpus  luteum  of  pregnancy  has  been  found  in 
the  ovary  on  the  side  opposite  to  the  gravid  cornu.  To 
explain  this  it  has  been  imagined  that  the  tube  reached 
across  the  middle  line  and  grasped  the  opposite  ovary, 
or  the  ovum,  after  leaving  the  gland,  say  of  the  left  side, 
entered  the  tubal  ostium  of  the  right  side.  Such  guesses 
do  not  call  for  serious  consideration. 

Pregnancy  in  one  horn  of  a  bicornuate  uterus  some- 
times gives  rise  to  difficulty  in  diagnosis,  mainly  on 
account  of  the  unilateral  position  of  the  gravid  horn. 

In  the  reported  cases  of  mistaken  diagnosis  the  error 
consisted  in  regarding  the  tumour  as  a  uterine  myoma. 

Angus  Macdonald  has  described  very  fully  a  case  of 
this  kind  which  occurred  in  a  w^oman  twenty-three  years 
of  age.  He  believed  the  tumour  to  be  a  rapidly-growing 
uterine  myoma.  Acting  on  this  opinion,  abdominal 
section  was  performed.  During  the  operation  it  was 
discovered  to  be  a  foetus-containing  tumour,  and  subse- 
quently the  nature  of  the  case  was  clearly  made  out. 
The  gravid  cornu  was  amputated,  and  the  patient  made 
a  good  recovery.  The  foetus  had  been  dead  several 
months. 

Amand  Routh  has  described  a  specimen  of  unicorn 
uterus  in  which  a  myoma  had  developed  in  connection 
with  the  undeveloped  horn. 

Literatinx    of  corjiual  /'r^,f'7/a;/r)/.  — Kussmaul's  classical  work, 


CoRNUAL  Pregnancy.  363 

published  in  1859,  contains  the  more  important  cases  up  to  that 
date.  In  our  home  literature  the  following  cases  may  be  con- 
sulted : — Turner:  Edi)i.  Med.  Join'ual,  1866,  vol.  xi.  p.  971; 
Struthers  :  Edin.  Med.  Journal,  vol.  vi.  p.  145  ;  Routh  :  Trans. 
Obstct.  Society,  London,  vol.  xxix.  pp.  2  and  58  ;  Jones 
(Handfield)  :  Ibid.,  vol.  xxix.  p.  146  ;  Macdonald  :  Obstet.  Trans., 
Edin.,  vol.  X.  p.  76.  This  paper  contains  some  references  to 
Werth's  and  Litzmann's  case  referred  to  below. 

In  addition,  consult  also — Virchow  :  Monatschrift  fiir  Gebiirts- 
kiinde,  i860 ;  Schroeder :  Krank.  der  Weib  Geschlechtorgane, 
1886  ;  Luschka  :  Monatsch.  filr  Geb.,  1863;  Werth  and  Litzmann  : 
Arch,  filr  Gyn.,  Bd.  xvii.  s.  281. 


;64 


CHAPTER  XXXIir. 

TWIN    GESTATION  :    ONE    FCETUS    INTRA-    THE    OTHER 
EXTRA-UTERINE. 

REPEATED    EXTRA-UTERINE    GESTATION. 

The  concurrence  of  tubal  and  uterine  gestation  is  very 
rare ;  but  instances  of  this  combination  have  been 
recorded.  Mr.  L.  R.  Cooke*  reported  a  case  of  this 
kind.  He  attended  a  woman,  aged  thirty-nine  years, 
whose  labour  was  difficult  in  consequence  of  a  tumour 
behind  the  uterus.  Mr.  Spencer  Wells,  who  saw  the  case, 
recognised  the  sound  of  two  foetal  hearts.  After  much 
difficulty,  Dr.  Greenhalgh,  who  was  consulted  in  the  case, 
extracted  a  child  from  the  uterus.  Two  days  later  the 
patient  died,  and  at  the  post  inortein  examination,  which 
was  attended  by  Dr.  Greenhalgh,  Spencer  Wells,  and 
others,  a  full-grown  fcetus  contained  in  its  membranes 
was  found.  "  Beneath  the  tumour  the  uterus  was  seen 
contracted  and  unruptured^"  The  anatomical  details  are 
not  given  in  full ;  those  who  saw  the  dissection  believed 
it  to  be  an  example  oititerine  and  extra-utei-ine pregnancy 
progressing  simultaneously  to  the  full  period  of  gestation. 

Dr.  Salet  has  described  a  case  of  this  kind  which 
occurred  in  a  negress  twenty-two  years  of  age.  Extra- 
uterine gestation  was  diagnosed,  and  abdominal  section 
performed  for  its  relief.  After  removal  of  the  foetus  from 
the  extra-uterine  sac,  the  uterus  was  recognised ;  it  was 

*   Trans.  Ohstet.  Soc,  London,  vol.  v.  p.  143. 

t  New  Orleans  Med.   and  Surg.    Journal,   Oct.,   1870;  and   Am. 
Journal  of  Obstet. ,  vol.  xiii.  p.  832. 


Intra-  and  Extra-Uterine  Pregnancy.     365 

"large  and  globular,  as  if  impregnated."  The  uterus 
was  opened,  and  another  living  child,  with  its  placenta, 
removed.  The  patient  died  on  the  fourth  day  after  the 
operation.     There  was  no  autopsy. 

Dr.  Wilson*  gives  a  detailed  account  of  a  case  in 
which  this  rare  combination  existed.  The  patient  was 
twenty-four  years  of  age,  the  mother  of  three  children. 
In  x\pril,  1880,  she  gave  birth  to  a  fourth  child  at  the 
eighth  month.  The  midwife  came  to  the  conclusion  that 
there  was  another  foetus,  and  sought  medical  advice.  It 
was  eventually  concluded  that  the  second  child  was 
extra-uterine  ;  the  movements  of  the  child  could  be.  felt, 
and  the  sound  of  the  fcetal  heart  was  plainly  audible. 
It  was  difficult  to  decide  whether  this  child  was  outside 
the  uterus  or  contained  in  the  horn  of  a  bicornuate 
uterus.  In  relation  to  this  point,  Dr.  Wilson  mentions 
that  on  one  occasion  Dr.  Goodell  diagnosed  extra- 
uterine pregnancy,  and  had  appointed  a  day  for  the  opera- 
tion ;  in  the  meanwhile  the  woman  was  taken  in  labour 
and  delivered  naturally  of  a  living  child.  She  had  a 
double  uterus. 

In  Dr.  Wilson's  patient  abdominal  section  was  per- 
formed ;  the  child  was  extra-uterine,  and  the  report 
states  that  the  sac  "  was  so  fragile  at  the  point  of  incision 
that  I  wondered  why  the  child  in  its  motions  had  not 
ruptured  it  before." 

The  placenta  was  left,  but  grave  symptoms  super- 
vening, an  unsuccessful  attempt  was  made  to  remove 
it.  The  patient  died  suddenly  ninety  hours  after  the 
operation. 

In  1 88 1  Dr.  Galabinf  recorded  an  instance  of  this 
which   happened    in   a  patient   thirty-six   years    of  age. 


*  Am.  Journal  of  Obstet.,  vol.  xiii.  p.  821. 

f   Trans,  Obstet.  Soc,  London,  vol.  xxiii.  p.  141. 


366  Tubal  Pregnancy. 

The  history  suggested  the  case  to  be  an  ovarian  cyst 
comphcated  with  pregnancy,  and  that  the  cyst  had 
ruptured.  A  combined  intra-  and  extra-uterine  gesta- 
tion was  regarded  as  possible.  Dr.  Galabin  performed 
abdominal  section.  On  opening  the  peritoneum  a  foetus 
was  discovered  enclosed  in  its  membranes  lying  to  the 
right  side  of,  above,  and  somewhat  behind  the  uterus. 
The  placenta  appeared  to  be  spread  out  very  widely,  and 
attached  chiefly  to  the  posterior  surface  of  the  right 
broad  ligament  and  of  the  pregnant  uterus.  The  placenta 
was  not  disturbed.  Two  days  later  labour  pains  came 
on,  and  the  intra-uterine  child  was  delivered  ;  it  was  dead. 

The  patient  continued  to  lose  blood  from  the  extra- 
uterine sac,  and  died  three  days  after  the  operation.  No 
autopsy  was  allowed. 

Several  similar  cases  have  been  recorded  in  periodical 
literature,  but  the  four  cases  thus  briefly  mentioned 
illustrate  the  leading  points  in  the  clinical  history  of  this 
accident.  Its  gravity  is  sufficiently  obvious,  for  in  all  the 
reported  cases  the  patients  died  within  a  few  days  of  the 
operation.  The  great  difficulty  in  this,  as  in  all  other 
examples  of  advanced  extra-uterine  gestation,  is  the 
excessive  risk  of  haemorrhage  which  follows  inter- 
ference with  the  placenta,  and  the  very  great  danger  the 
patient  runs  of  dying  from  septicemia  if  it  be  allowed 
to  remain.  A  distinction  must  be  drawn  between  co?i- 
current  intra-  and  extra-uterine  gestation  and  intra-uterine 
gestation  subsequent  to  tubal  pregnancy. 

Repeated  tubal  g-estatioii. — Parry  has  grouped 
under  this  heading  several  cases  of  "women  who  have  been 
known  to  bear  more  than  one  extra-uterine  child ; "  but 
it  may  be  at  once  stated  that  of  the  nine  cases  adduced 
by  Parry  not  one  can  be  regarded  as  of  the  least  value 
in  establishing  such  an  occurrence.  Indeed,  in  one 
instance   he   is    so   credulous    as  to    believe    that   tubal 


Repeated  Tubal  Pregnancy,  367 

pregnancy  may  happen  twice  in  the  same  tube.  The 
case  in  question  is  reported  in  great  detail  l^y  Dr. 
Haydon,  whose  account  is  supplemented  by  a  report  on 
the  specimen,  signed  by  Drs.  Tyler  Smith  and  Braxton 
Hicks.*  This  paper  is  illustrated  by  a  plate,  from  which 
it  seems  exceedingly  probable  that  the  patient  had  a 
bicornuate  uterus.  Repeated  gestation  in  the  same  tube 
is  an  impossibility,  for  the  pregnancy  produces  such 
gross  changes  as  to  render  it  functionless. 

Instances  reported  as  repeated  tubal  gestation  are  of 
no  value  when  the  evidence  rests  merely  on  physical 
signs.  True  knowledge  must  rest  on  such  facts  as  in 
the  following  case  : — 

McG ,    aged   twenty-eight    years,    was    admitted 

into  the  London  Hospital  January,  1887,  and  underwent 
abdominal  section  for  tubal  gestation  which  had  ruptured 
into  the  peritoneal  cavity.  In  this  operation  Dr.  Herman 
removed  the  right  tube. 

In  December,  1888,  the  patient  was  again  in  the 
hospital,  suffering  from  enteric  fever.  She  was  re- 
admitted into  the  hospital  on  May  13th,  1890.  Men- 
struation occurred  for  the  last  time  in  P'ebruary,  and 
having  since  often  felt  sick,  she  thought  she  was  preg- 
nant. She  was  very  low-spirited,  and  this  circumstance 
led  to  her  seeking  advice.  On  May  loth  she  had 
slight  vaginal  hemorrhage.  She  had  had  no  pain  except 
that  produced  by  the  vomiting. 

On  vaginal  examination  the  uterus  was  found  in 
the  normal  position,  and  quite  movable.  To  the  left  of 
and  behind  the  uterus  was  a  swelling  about  as  large  as 
the  uterus,  and  moving  with  it.  The  patient  was  fat 
and  not  ansemic,  and  there  were  no  signs  of  disease 
elsewhere. 

*    Trans.  Obstct.  Soc. ,  London,  vol.  v.  p.  280. 


368  Tubal  Pregnancy. 

The  clinical  history  and  the  physical  signs  pointed 
to  a  pregnancy  in  the  left  tube.  Its  removal  by  opera- 
tion was  therefore  advised,  and  performed  on  May  17th. 
The  abdomen  was  opened  by  an  incision  in  the  line  of 
the  former  one.  When  exposed,  the  left  tube  was  seen 
as  a  purplish-red,  elongated,  ovoid  swelling,  lying  by  the 
side  of  the  uterus,  and  having  its  long  axis  parallel  with 
that  of  the  uterus.  It  was  connected  to  the  uterus  by 
soft,  easily  broken-down  adhesions.  These  were  easily 
separated,  the  broad  ligament  transfixed  and  tied,  and 
the  tube  removed  entire  along  with  the  ovary.  Under 
the  compression  used  in  its  removal,  blood  spirted  from 
a  little  hole  not  larger  than  a  pin  puncture.  The  peri- 
toneal cavity  was  washed  out  with  water.  Some  recent 
clot  was  found  at  the  bottom  of  the  recto-vaginal  pouch, 
but  as  the  tube  was  entire,  this  may  have  come  from 
separated  adhesions  or  from  the  wound. 

The  tube  removed  measured  2|  inches  long  by  i|^ 
inch  across.  When  cut  open,  a  foetus  about  a  third  of 
an  inch  long  was  found  within  it.  Its  interior  was 
mammillated,  just  like  the  interior  surface  of  an 
apoplectic  ovum,  and  the  amniotic  cavity  contained  an 
embryo.  Its  wall,  on  section,  was  three-eighths  of  an  inch 
thick,  and  to  the  naked  eye  resembled  the  thrombosed 
placenta  of  an  extra-uterine  gestation  some  time  after 
the  death  of  the  child.* 

The  details  of  an  equally  convincing  case,  reported 
by  Lawson  Tait,  are  briefly  these  : — 

A  woman  twenty-five  years  of  age  came  under  his 
care  in  1885,  suffering  from  severe  abdominal  trouble. 
She  believed  herself  pregnant.  Menstruation  had  been 
suspended  for  three  months.  When  the  woman  was 
seen  by  Mr.  Tait  she  looked  extremely  ill  and  anaemic  ; 

*  British  Med.  Jounial,  1890,  vol.  ii.  p.  722. 


Twin  Tubal  Gestation.  369 

on  the  previous  day  she  had  had  an  attack  of  fainting, 
accompanied  by  vomiting.  A  large  ill-defined  mass 
existed  on  the  right  side,  and  intimately  associated  with 
the  uterus.  The  case  was  regarded  as  one  of  tubal 
pregnancy,  which  had  ruptured.  Abdominal  section  was 
performed,  and  a  ruptured  gestation  sac,  fcetus,  and 
placenta  were  removed.  The  patient  made  a  rapid 
recovery. 

Eighteen  months  after  this  operation  she  was  con- 
fined of  a  child  at  full  term.  About  fifteen  months 
after  this  confinement  she  again  became  pregnant. 
After  turning,  according  to  her  computation,  the  fourth 
rnonth,  she  was  suddenly  seized,  whilst  in  the  act  of 
stooping,  with  acute  pain  and  a  feeling  of  faintness. 
Stimulants  were  administered  and  every  effort  was  made 
to  restore  her,  but  she  died  in  five  hours  from  the  com- 
mencement of  the  attack.  At  the  post  mortem  examina- 
tion the  abdomen  was  found  full  of  blood-clot  which  had 
come  from  a  rent  in  the  uterine  wall.  The  uterus  was 
removed  and  carefully  dissected.  The  ovum  had  been 
lodged  in  the  uterine  section  of  the  left  tube.  The 
account  of  the  anatomy  of  the  parts  and  the  drawing 
which  illustrates  it  show  the  gestation  to  belong  to  the 
tubo-uterine  variety.  The  stump  of  the  right  tube  was 
clearly  made  out,  and  a  fine  probe  could  be  passed  into 
it  from  the  cavity  of  the  uterus.  The  uterine  cavity  was 
lined  by  a  decidua.* 

Twin  tul>at  g-estatioii.— This  may  be  interpreted 
in  two  senses  :  it  may  signify  gestation  running  con- 
currently in  each  tube  or  two  embryos  in  one  tube, 
that  is,  twin  pregnancy  in  the  ■  ordinary  acceptation  of 
the  term.  Of  twins  developing  in  tubal  pregnancy  we 
have  no  trustworthy  evidence. 

*  Lectures  on  Ectopic  Pregnancy,  p.  46  ;  1888. 
Y 


37C  Tubal  Pregnancy. 

Gestation  occurring  simultaneously  in  both  tubes  of 
the  same  patient  is  possible,  although  evidence  for  it 
is  not  abundant  A  case  worth  mention  in  this  direc- 
on  has  been  reported  in  Australia.  Dr.  T.  Rowan"^ 
relates  briefly  six  cases  of  tubal  pregnancy.  The  most 
important  occurred  in  a  woman  twenty-nine  years  of  age, 
who  was  seized  with  typical  signs  indicating  primary 
rupture  of  a  gravid  tube.  During  the  operation  both 
tubes  were  found  distended  ■  the  left  ruptured  during 
removal.  The  right  tube  was  dilated  to  the  size  of  a 
hen's  egg,  and  when  cut  open  revealed  a  large  piece  of 
placental  tissue  firmly  adherent  on  one  side,  and  quite 
free  elsewhere.  No  sign  of  an  embryo  was  discovered. 
Dr.  Rowan  had  no  doubt  that  it  was  "a  tubal  pregnancy 
of  some  six  or  seven  weeks,  which  was  undergoing 
retrograde  changes." 

On  the  left  side  the  tube  was  dilated  into  a  cyst  the 
size  of  an  orange  :  it  was  filled  with  grumous  blood. 

The  evidence  in  this  case,  though  strongly  suggestive, 
is  not  sufficiently  precise  to  establish  the  existence  of  a 
pregnancy  in  each  tube.  There  is  little  doubt  that  some 
decisive  example  of  this  coincidence  will  before  long  be 
forthcoming. 

Twisa  cosiceptiosi  iai  extra  uterine  g^estatioii. 
— Dr.  Robert  Barnes  f  writes  : — "  It  has  struck  me  as 
remarkable  how  often  in  tubal  gestation  twins  have  been 
found."  He  then  hazards  the  following  guess  :-  — "  May 
it  not  be  that  two  ova  may  obstruct  each  other  in  their 
passage  along  the  tube  ?  " 

Parry;]:  takes  up  the  hint,  and  writes  : — "  Among  five 
hundred  cases  of  extra-uterine  conception,  collected 
without   any   selection,  there  were  twenty-two  cases   of 

*  Australian  Med.  Journal  1890,  p.  265. 

+  Clinical  Lectures  on  Diseases  of  Women,  p.  421. 

j  Extra--itterine  Pregnancy,  pp.  27  and  138. 


Twin  Tubal  Gestation.  371 

combined  intra-  and  extra-uterine  pregnancy.  In  other 
words,  in  round  numbers,  two  ova  were  fertilised  at  the 
same  time  in  one  out  of  every  twenty-three  gestations. 
Churchill,  the  highest  statistical  authority  upon  obste- 
trics who  has  written  in  our  language,  says  that  there  is 
one  twin  in  every  seventy-five  conceptions  among  British 
matrons^  one  in  one  hundred  and  eight  among  the 
French,  and  one  in  every  eighty-seven  among  German  : 
or  an  average  of  one  in  ninety  among  the  mothers  of  the 
three  countries.  From  these  data  it  would  follow  that 
twin  conceptions  are  about  four  times  as  frequent  in 
extra-uterine  as  they  are  in  normal  foetations." 

In  another  part  of  the  book  Parry  puts  it  in  a  some- 
what different  way.  He  writes: — "Attention  has  been 
called  to  the  fact  that  twin  conceptions  are  much  more 
frequent  in  extra-uterine  than  they  are  in  normal  gesta- 
tions. It  is  a  striking  fact,  however,  that  both  children 
are  rarely  developed  in  the  same  locality.  In  a  large 
majority  of  these  tubal  conceptions  one  ovum  finds  its 
way  into  the  interior  of  the  uterus,  while  the  other  is 
arrested  at  some  point  in  its  descent.  This  fact  has  led 
Professor  Barnes  to  believe  that  twin  conception  is  one 
cause  of  extra-uterine  gestation." 

A  critical  study  of  the  cases  referred  to  by  Parry 
shows  that  he  not  only  founded  his  opinion  on  un- 
trustworthy reports,  but  that  he  confounded  together 
three  distinct  conditions  : — 

T.    Co7icurrent  tubal  and  uterine  gestation. 

2.  Twin  gestation  in  a  Fallopian  tube. 

3.  Uterine  gestation  subsequent  to  tubal  pregnancy. 
The  first  condition  has  already  been  discussed  in  this 

chapter ;  also  the  question  of  twin  gestation  in  one  tube, 
as  well  as  gestation  occurring  concurrently  in  both  tubes. 
The  third  section  is  of  some  interest,  and  will  be  con- 
sidered in  the  ensuing  chapter. 

Y    2 


372 


CHAPTER    XXXIV. 

RETENTION      OF      THE      FCETUS. 

In  tubal  pregnancy  the  life  of  the  embryo  is,  as  has  been 
shown  in  the  immediately  preceding  chapters,  very  pre- 
carious. '  Yet  in  the  face  of  all  these  possibilities  the 
gestation  may  run  on  to  term.  Then  symptoms  of  labour 
set  in,  and  as  delivery  by  the  natural  channels  is  an  im- 
possibility, the  gestation  sac  may  rupture  into  the  peri- 
toneal cavity,  with  all  its  attendant  evils.  Escaping  this 
catastrophe,  the  foetus  dies,  and  may  remain  quiescent 
or  give  rise  to  various  forms  of  disturbance. 

In  the  more  fortunate  cases  the  unavailing  labour  is 
followed  by  absorption  of  the  liquor  amnii,  and  the 
tissues  of  the  foetus  may  become  Jiiiiinniified^  or  partially 
calcified  to  form  a  lit/iopcedioii ;  the  soft  parts  may  be 
converted  into  adipocere,  or  the  tissues  may  decompose. 

Miiiiiiiiilication. — To  produce  this  condition  the 
fluid  parts  become  absorbed,  and  the  soft  parts  are  con- 
verted into  dry  tough  tissue,  so  that  the  foetus  resembles 
a  mummy,  or  the  dried  cats  so  commonly  found  under 
the  floors  of  old  dwellings. 

The  characters  of  such  a  foetus  are  well  shown  in 
Fig.  107.  "It  is  a  foetus  almost  completely  developed, 
but  compressed  and  dried,  so  that  little  more  than  the 
bones  remain  to  indicate  its  previous  form.  It  is  reduced 
to  a  flattened  irregular  mass,  about  four  inches  long  and 
from  two  to  three  inches  wide.  The  general  form  of 
the  head  and  the  outlines  of  its  several  bones,  as  well 
as    some   of    the   ribs,    the    fore -arms    and    hands,    the 


Adipocere. 


373 


knee-joints,  and  parts  of  the  lower  extremities,  are  dis- 
tinct; but  the  parts  between  them  are  shrivelled  and  partly 
calcified.    The  foetus  was  removed  by  operation  from  the 


EYE 


NOSE 


KNEE 


Fig.  107.  — Lithopaedion.     (Museum,  Royal  College  of  Surgeons.) 


Fallopian  tube  (as  it  was  believed)  ot  a  woman  in  whom 
it  had  been  retained  more  than  fourteen  years  beyond 
the  ordinary  period  of  gestation." 

Adipocere  is  a  peculiar  substance,  intermediate  be- 
tween fat  and  wax ;  usually  it  is  white  in  colour,  and  is 
chemically  an  ammoniacal  soap,  being  formed  by  the  union 


374  Tubal  Pregnancy. 

of  a  fatty  acid  with  ammonia.  The  formation  of  adipocere 
depends  therefore  on  the  presence  of  fat,  the  ammonia 
being  supphed  by  the  decomposition  of  the  tissues. 
FQlly-formed  adipocere  is  structureless,  but  unchanged 
-tissue,  such  as  fragments  of  muscle  and  bone,  may  be 
mixed  with  it.  As  the  formation  of  adipocere  depends 
upon  the  presence  of  fat,  it  naturally  follows  that  it  should 
occur  easily  in  the  foetus,  which  at  and  near  term  con- 
tains a  thick  stratum  of  fat  immediately  beneath  the  skin. 
The  presence  of  water  is  necessary  for  the  formation  of 
adipocere ;  hence  this  process  takes  place  in  bodies  lying 
in  damp  soil  or  in  water.  Concerning  the  length  of  time 
necessary  for  this  change  to  take  place  in  dead  bodies 
wc  have  no  positive  knowledge,  but  it  requires  at  least  a 
few  months  ;  it  is  probable  that  the  encystment  of  a  foetus 
in  soft  and  moist  tissues  between  the  layers  of  the  meso- 
metrium  is  a  condition  favourable  for  the  formation  of 
adipocere. 

There  is  a  circumstance  in  connection  with  these 
foetuses  which  are  partially  or  wholly  converted  into 
adipocere  which  is  of  some  practical  importance  :  this  is 
the  great  tendency  they  exhibit  to  adhere  to  the  tissues 
forming  the  wall  of  the  sac  in  which  they  lie. 

When  a  foetus  is  converted,  wholly  or  partially,  into 
adipocere,  or  mummified,  its  superficial  parts  and  the 
walls  of  the  gestation  sac  are  liable  to  become  calcified. 
A  foetus  encrusted  with  lime-salts  in  this  way  is  termed  a 
lUliopsedioii.  In  some  specimens  parts  of  the  foetus 
are  converted  into  adipocere,  whilst  other  parts,  even  the 
internal  organs,  undergo  calcification,  or  portions  may 
be  calcified,  and  subsequently  mummified. 

The  most  remarkable  case  of  retention  of  an  extra- 
uterine foetus  on  record  is  the  one  described  by  Cheston* 

*  Medico-Chir.  Traits.,  vol.  v.  p.  104. 


Lit  I  10  PMD  ION.         •  375 

in  1814-  In  1738  a  woman  was  taken  in  labour  with 
her  fourth  child  ;  the  doctor  in  attendance  declared  it 
could  not  be  delivered  without  the  aid  of  instruments. 
To  this  the  patient  would  not  consent,  declaring  that 
rather  than  submit  to  instrumental  delivery  "  she  and  the 
child  should  die  together."  The  child  did  not  come 
away,  and  the  patient  survived  the  accident  fifty-two 
years,  and  died  in  1790,  at  the  age  of  eighty  years. 
Before  death  she  had  arranged  that  the  body  should  be 
examined.  At  the  dissection  a  lithop^dion  was  found 
in  the  pelvis.  A  portion  of  the  specimen  is  preserved 
in  the  museum  of  the  Royal  College  of  Surgeons. 

In  1881  Doran  re-investigated  the  specimen,  at  the 
suggestion  of  Dr.  Robert  Barnes.*  He  found  the  abdo- 
minal and  thoracic  viscera  quite  soft,  but  impregnated 
with  lime-salts.  The  integuments  and  subcutaneous 
tissue  of  the  front  of  the  thorax  and  abdomen  are  very 
thick  and  infiltrated  with  lime-salts,  so  as  to  feel  gritty. 
The  integument  and  subcutaneous  tissues  of  the  posterior 
part  of  the  trunk  are  very  thin,  and  converted  into  hard 
calcareous  plates. 

Dr.  Barnes,  in  the  same  paper,  drew  attention  to  a 
similar  specimen  preserved  in  the  museum  of  St. 
Thomas's  Hospital.  In  this  instance  the  specimen  had 
been  retained  in  the  abdomen  forty-three  years.  It  was 
carefully  investigated  by  Mr.  Stewart.  It  has  all  the 
appearance  of  an  embryo  which  had  reached  full 
development.  It  was  doubled  up  and  compressed  into 
a  ball,  enveloped  in  a  sac,  which  fits  so  closely  to  its 
limbs,  trunk,  and  head  that  no  more  than  the  general 
outHne  of  the  parts  could  be  made  out.  This  envelope 
consists    of  the    cyst  wall    and   membranes ;   the   parts 

*  "On    the    so-called     Lithopaedion ; "    Trans.    Obsiet.    Soc,    vol. 
xxiii.  p.  170.  '  . 


37^  Tubal  Pregnancy. 

generally  have  undergone  "  adipocerous  and  cretaceous 
metamorphosis."  The  skin  of  the  foetus  had  also 
become  calcified,  and  the  deeper  parts,  including  the 
viscera,  were  found  more  or  less  impregnated  with  lime- 
salts.  The  term  lithopcedwu  does  not  signify  that  the 
foetus  is  converted  into  stone,  but  that  its  tissues  are 
impregnated  with  lime-salts — that  is,  calcified. 

Unfortunately,  the  majority  of  foetuses  sequestrated 
in  the  mesometrium  do  not  remain  quiescent,  for  the 
proximity  of  the  intestinal  tract  leads  to  adhesion  of  the 
intestines,  especially  the  rectum,  to  the  sac  wall,  and  in 
many  cases  the  tissues  dividing  them  become  so  thin  that 
gases  from  the  bowel  find  their  way  into  the  sac  and  set 
up  decomposition  of  the  foetal  tissues,  and  cause  sup- 
puration. 

This  is  a  matter  of  some  interest,  for  it  has  been 
many  times  asked — How  is  it  that  in  some  cases  an 
extra-uterine  foetus  seems  quite  fresh,  even  after  it  has 
been  dead  for  months,  or  remains  innocuous  as  a  litho- 
paedion,  whilst  in  many  it  decomposes  rapidly,  and 
becomes  surrounded  by  pus?  The  answer  is  simple 
enough  :  so  long  as  the  foetus  is  excluded  from  contact 
with  air  or  intestinal  gases,  it  is  as  safely  preserved  as  a 
specimen  in  an  air-tight  jar,  but  as  soon  as  air  is  ad- 
mitted, or  gases  from  the  intestines  gain  access  to  it, 
putrefactive  changes  at  once  begin. 

The  length  of  time  a  dead  foetus  may  remain  quiescent 
in  the  mesometrium  is,  of  course,  impossible  to  deter- 
mine ;  and  though  it  may  remain  long  enough  to  undergo 
conversion  into  adipocere,  or  even  become  a  lithopaedion, 
it  may,  even  years  after,  decompose.  Whether  this  event 
follows  within  a  few  weeks,  or  be  delayed  months,  or 
perhaps  years,  the  effects  produced  by  it  are  much  the 
same.  A  collection  of  pus  forms  in  the  cavity,  and,  as  in 
an    abscess   in    the    broad   ligament  arising  from   other 


Decomposition  of  the  Fcetus. 


377 


causes,  the  pus  attempts  to  find  an  outlet  along  the  Ihies 
of  least  resistance.  Thus  it  may  open  into  the  rectum  ; 
this  would  appear  to  be  the  most  frequent  direction. 
Often  the  pus  will  burrow  its  way  through  the  vagina, 


r 


'/•■r/  i-//'.:\v.\\\0''\    ,  ,  .fill, 


RIBS 


SCAPULA 


Fig.  io3. — Mass  of  Foetal  Bones  from  a  ca.se  of  Extra-Uterine  Pregnancy. 

(Museum  of  the  Middlesex  Hospital.) 

All  the  soft  parts  and  the  cartilages  from  the  ends  of  the  bones  have  decaj-ed. 

and  not  uncommonly  makes  its  way  into  the  bladder. 
Gervis*  has  recorded  a  case  in  which  the  abscess  opened 
into  the  uterine  cavity,  and  the  bones  discharged  through 
the  cervical  canal.     Sometimes  such  abscesses  present 


*  Medico-Chir,  Trans.,  vol.  Ixx.  p.  35. 


S7^  Tubal  Pregnancy. 

immediately  above  Poupart's  ligament,  and  even  point  at 
the  umbilicus.  In  whichever  way  they  attempt  to  gain 
the  surface,  we  find  that  a  sinus  forms  allowing  of  the 
escape  of  pus,  and  sooner  or  later,  fragments  of  the  fcetus, 
especially  the  shafts  of  the  long  bones  or  portions  of  the 
vertebrae,  escape  from  the  opening.  In  some  cases  the 
discharge  of  pus,  which  at  first  is  very  free  and  offensive, 
gradually  diminishes,  and  leaves  a  sinus  which  persists 
for  years. 

When  such  cases  are  examined  after  death,  the  old 
gestation  sac  is  found  firmly  contracted  on  a  conglomerate 
mass  of  foetal  bones,  without  the  least  particle  of  soft 
material,  or  even  cartilage.  Such  a  mass  is  sketched  in 
Figs.  1 08  and  109.  The  specimen  is  preserved  in  the 
museum  of  the  Middlesex  Hospital. 

An  examination  of  these  specimens  shows  that  as 
the  soft  parts  of  the  foetus  decay  and  are  discharged,  the 
walls  of  the  sac  gradually  shrink  upon  and  compress 
tlie  skeleton.  An  examination  of  the  mass  shows  that 
the  bones  of  the  arms  and  legs  maintain  the  folded  posi- 
tion assumed  by  them  as  the  foetus  lies  closely  girt  about 
by  the  sac  in  which  it  was  developed. 

When  discussing  the  complications  and  combinations 
of  tubal  pregnancy,  it  was  mentioned  that  women  may 
conceive  in  the  uterus  after  having  conceived  in  the  tube  : 
that  is,  a  woman  may  have  a  lithop^edion  or  the 
macerated  skeleton  of  a  foetus  between  the  layers  of  the 
broad  ligament,  and  yet  conceive  in  her  uterus. 

Stonham*  has  demonstrated  this  in  a  woman  fort3^-three 
years  of  age,  who  died  in  the  seventh  month  of  pregnancy 
from  bronchitis  and  ulceration  of  the  trachea.  At  iwtpost 
viorteui  examination  a  foetus  enclosed  in  thick  membrane 
was  discovered  in  the  right  broad  ligament.     Some  of  the 

*   Trans.  Path.  Soc,  Londo?z,  vol.  xxxviii.  p.  445. 


Retention  of  the  Fletus. 


379 


bones  were  completely  macerated  ;  the  soft  structures 
were  soapy  in  consistence.  There  was  a  thin  deposit  of 
calcareous  material  on  the  inner  walLof  the  cyst.  The 
left  broad  ligament  was  normal.      The  uterus  contained  a 


JAW 


UR 


VERTEBRA 

109. — Another  View  of  the  same  Group  of  Bones  sketched  in  Fi^. 


io3. 


seven  months'  foetus  which  was  apparently  livi?ig  at  the 
mother's  death,  si?ice  it  showed  no  sig?is  of  maceration. 

Dr.  Worrall,*  of  Sydney,  has  published  the  details  of 
a  case  in  which  a  woman  with  a  fcetus  retained  in  the 
broad  ligament  subsequently  conceived  in  the  uterus. 
The  nature  of  the  case  was  correctly  diagnosed,  and  an 


*  Afedical  Press  and  Ciraclar,  March  25th,  1891. 


3^o  Tubal  Pregnancy, 

operation  for  the  relief  of  the  condition  was  successfully 
carried  out. 

The  patient  was  thirty  years  of  age,  and  mother  of  five 
children.  In  April,  1888,  the  menses  having  been  absent 
six  weeks,  she  was  seized  in  the  night  with  severe  ab- 
dominal pains,  faintness,  and  vomiting.  She  was  con- 
fined to  her  bed  six  weeks.  In  October  of  the  same 
year,  in  about  the  eighth  month  of  gestation,  a  sudden 
flooding,  unaccompanied  by  pain,  came  on,  and  lasted 
three  days.  A  month  later  she  was  seized  with  severe 
abdominal  pains,  which  lasted  a  fortnight ;  she  then 
began  to  decrease  in  size,  and  menstruation  re-appeared. 
The  tumour  decreased  to  a  certain  point,  and  then  re- 
mained stationary. 

After  July,  1889,  she  ceased  to  menstruate,  and  "her 
abdomen  gradually  enlarged.  A  few  months  later  Dr. 
Worrall  was  consulted,  and  he  correctly  diagnosed  the 
existence  of  a  living  intra-uterine  fcetus  and  an  extra- 
uterine fcetus  which  had  been  dead  about  two  years. 

Acting  on  this  diagnosis,  he  removed  the  extra- 
uterine foetus  from  the  left  broad  ligament.  It  was  not 
decomposed,  but  was  very  flaccid,  and  weighed  \^  lbs. 
The  placenta  was  left,  and  the  sac  drained.  Next  day 
labour  came  on,  and  the  intra-uterine  child  was  born.  It 
was  a  female,  and  cried  feebly,  "  but,  in  spite  of  every  care, 
died  in  a  few  hours."    The  patient  made  a  good  recovery. 

Bozeman*  has  recorded  a  case  in  which  uterine 
supervened  on  extra-uterine  gestation.  After  dehvery  of 
the  intra-uterine  child  an  uneven  and  projecting  mass  pre- 
sented in  Douglas's  fossa.  This  proved  to  be  the  sac  of 
an  extra-uterine  pregnancy.  From  the  history  of  the  case 
it  had  probably  been  dead  between  three  and  four  years. 
The  contents  of  the  sac  were  evacuated  through  the 
vagina.     The  patient  recovered. 

*  New  York  Med.  Jourjial,  1884,  vol.  xl.  p.  693. 


3^1 


CHAPTER    XXXV. 

TUBAL    GESTATION    IN    THE    LOWER    MAMxMALS. 

The  subject  of  tubal  gestation  in  the  lower  mammals  is 
somewhat  outside  the  province  of  this  work;  it  will  there- 
fore be  very  briefly  considered.  It  is,  however,  important 
to  mention  it,  because  a  few  of  the  specimens  to  be 
described  are  useful  in  throwing  light  upon  some  condi- 
tions met  with  in  extra-uterine  foetuses  in  the  human  sub- 
ject, and  also  because  it  serves  to  reflect  some  of  the 
confusion  prevailing  on  the  subject  of  tubal  pregnancy 
generally  up  to  the  last  five  years. 

A  prolonged  and  wide  search  through  veterinary 
literature,  and  an  examination  of  a  few  museum  specimens 
supposed  to  illustrate  extra-uterine  gestation,  has  con- 
vinced me  that  therx  is  no  specimen  or  description  of  a  case 
of  tubal  pi'egnancy  in  a  niainnial  other  tJian  the  human 
female  that  will  bear  criticism.  It  may  be  at  once  pointed 
out  that  the  mistake  is  due  to  the  circumstance — especially 
when  the  cases  are  recorded  by  medical  practitioners — 
that  the  reporters  invariably  mistake  the  elongated  uterine 
cornua  for  the  Fallopian  tubes.  This  is  not  surprising 
when  we  remember  that  in  so  many  mammals  the  tubes 
are  rarely  thicker  than  ordinary  whip-cord,  and,  in  addi- 
tion, are  usually  curled  up  and  partially  concealed  in  the 
walls  of  the  ovarian  sac.  With  a  little  care,  however,  and 
using  the  abdominal  ostium  of  the  tube  as  an  indicator, 
no  difficulty  should  be  experienced.  In  the  accompany- 
ing figure  a  sketch  of  the  uterus  of  an  ewe  with  its  cornua 
and  tubes  shows  the  general  relation  of  the  parts  when 
they  are  stretched  out  (Fig.  no). 


382 


Tubal  Pregnancy. 


The    conditions    usually   reported    as    extra-uterine 
gestation  are  due  to  two  causes  : — 

I.  Abnormal  retention  of  the  foitus  in  the  uterus. 


-CERVIX 


Fi'J.  no. — Uterus  of  an  Ewe. 


2.   Rupture  of  a  gravid  uterus  or  one  of  its  cornua,  and 

■  retention  of  the  embryo  in  the  peritoneum  or  S2cb- 

peritoneal  tissue. 

In  domesticated  mammals  the  gestation  period  for  a 

given  species  varies  within  certain  limits.    Hence  :  eleven 

months  for  a  mare,  nine  months  for  a  cow,  five  months 

for  ewes  and  goats,  four  months  for  sows,  two  months 


Retention  of  a    Uterine  Fcetus.  383 

for  the  bitch  and  cat,  are,  Hke  nine  months  for  women, 
only  average  periods. 

Pregnancy  may  in  cows  or  mares  over-run  the  average 
by  a  few  days,  two  weeks,  a  month,  or  even  more,  and  a 
healthy  fcetus  be  born.  With  such  conditions  we  are 
not  concerned. 

The  expression  abnormal  7'efention  of  a  fcetus  is 
applied  to  those  cases  in  which  an  animal  goes  full  terra, 
and  then  passes  through  an  ineffectual  labour ;  the  pains 
pass  away,  the  abdominal  enlargement  subsides,  and, 
as  a  rule,  the  ;-///  fails  to  appear,  the  animal  remaining 
permanently  sterile. 

The  Causes  of  Abnormal  Retention  are  : — 

1.  Ufiusual  size  of  the  fattis. 

2.  Torsion  of  the  uterus  or  one  of  the  coniiia. 
It  is  well  known  that  when  the  male  is  large  and  out 

of  proportion  to  the  female,  the  fcetus  may  be  too  large 
to  pass  through  the  pelvis.  An  example  of  this  is 
sketched  in  Fig.  in.  The  drawing  represents  the  pelvis 
and  uterus  of  a  Macaque  monkey  {Afacacus  sinicus) 
which  died  during  delivery.  When  the  keeper  left  the 
monkey-house  in  the  evening  he  noticed  the  animal  was 
restless.  On  his  return  next  morning  he  found  it  dead, 
with  the  limbs  and  trunk  of  a  full-time  foetus  protruding. 
The  pelvis  was  far  too  small  to  allow  the  head  to  pass 
out.  I  presented  the  specimen  to  the  museum  of  the 
Royal  College  of  Surgeons  (4,2  74a). 

The  foetus  may  be  retained  from  unexplained  causes. 
One  of  the  most  remarkable  instances  of  this  is  the 
specimen  presented  to  the  museum  of  St.  Bartholomew's 
Hospital  by  Dr.  Matthews  Duncan.  The  history  of  the 
case  is  briefly  this  : — 

The  Earl  of  Southesk's  famous  cow,  Esmeralda,  was 
served  July  7th,  1865.     She  had  rinderpest  in  December 


384 


Tubal  Pregnancy. 


of  the  same  year,  when  probably  the  fuetus  died,  and  the 
cow  recovered.     There  were  no  signs  of  labour  during 


BLADDER 


Fig.  III. — Incomplete  Delivery  in  a  Monkey,  due  to  abnormal  size  of  the 
Foetus.     (Museum,  Royal  College  of  Surgeons.) 

the  rinderpest  or  at  the  date  when  pregnancy  should 
normally  terminate.  She  was  regarded  as  having  become 
sterile,  and  was  fattened  for  the  butcher.  In  October, 
1867,  the  almost  forgotten  pregnancy  was  brought  to 
recollection  by  the  discharge  of  a  mummified  calf  with- 
out anything  like  the  usual  manifestation  of  labour.     It 


A  Mummified  Calf, 


385 


is,  of  coarse,  possible  that  the  death  of  the  calf  was  the 
cause  of  its  retention  (Fig.  112). 

This  case  presents  an  unusual  feature,  for  the  rule  is 


Fig.    112. — MutnmifieJ    Calf   retained    in    the    Uterus   eighteen   months. 
(Museum  of  St.  Bartholomew's  Hospital.) 

that  when  a  fcetus  is  retained  in  the  uterus  from  causes 
other  than  torsion,  it  rapidly  undergoes  putrefaction.  In 
some  it  becomes  converted  into  adipocere. 

The  museum  of  the  Royal  College  of  Surgeons  con- 
tains some  specimens  illustrating  this  condition,  taken 
from  cows  and  ewes.     One  of  them  is  "  a  portion  of  the 


386 


Tubal  Pregnancy. 


horn  of  the  uterus  of  a  sheep,  .containing  the  head  and 
one  of  the  feet  of  a  lamb,  which  remained  in  the  uterus 
beyond  the  ordinary  period  of  gestation,  and  became 


UTERINE  CORN 


FOOT 


Fig.  113. — Head  and  one  of  the  Feet  of  a  Lamb  retained  in  the  Uterus. 
(Museum  of  the  Royal  College  of  Surgeons.) 


adherent  to  the  surrounding    uterine  wall"  (Fig.    113). 
Several  of  these  specimens  are  Hufiterian. 

When  a  foetus  is  retained  and  air  gains  access  to  it, 
or  in  consequence  of  adhesion  to  the  bowels  intestinal 
gases  enter  the  gestation  sac,  decomposition  rapidly  en- 
sues, and  the  soft  parts  speedily  decay  and  make  their 


Rotation  of  the   Uterus.  387 

escape,  accompanied  by  putrid  and  highly  offensive  dis- 
charges, either  through  the  vagina  or  rectum,  or  by 
fistulous  tracts  in  the  abdominal  wall.  Occasionally  the 
bones  will  come  away,  but  more  frequently  they  are 
retained,  and  when  the  animal  dies  or  is  killed,  the 
uterus  is  found  filled  with  a  more  or  less  completely 
macerated  skeleton  (Fig.  114). 

Axial  rotation  (twisting  or  torsion  of  the  gravid 
uterus)  is  an  interesting  accident.  It  has  been  most 
carefully  studied  in  the  cow.  The  whole  uterus  may 
rotate,  the  twists  involving  the  vagina  and  cervix  uteri. 
The  rotation  may  vary  from  half  a  turn  to  three  or  more 
complete  revolutions.  The  directions  of  the  twist  may 
be  to  the  right  or  to  the  left. 

Complete  torsion  offers  an  effectual  barrier  to  de- 
livery, unless  help  is  afforded  by  art,  and  this  is  rarely  of 
much  service.  The  effect  upon  the  cow  is  often  to  cause 
death  by  haemorrhage,  exhaustion,  or  rupture  of  the 
uterus.  In  rare  cases  the  cow  survives  the  accident,  re- 
mains sterile,  and  the  true  nature  of  the  case  is  revealed 
when  the  animal  is  handed  over  to  the  butcher.  Under 
such  conditions  the  fcetus  is  found  either  as  a  litho- 
psedion  or  as  a  mummy. 

When  the  torsion  involves  one  cornu,  it  may  be  so 
complete  as  to  actually  lead  to  its  detachment. 

Mr.  Hutchinson*  reported  a  specimen  of  this  which 
he  met  with  in  a  hare.  The  abdomen  contained  a 
rounded  tumour  as  large  as  a  big  orange.  The  tumour 
fell  out  when  the  belly  was  opened.  On  careful  dissec- 
tion, it  was  found  to  be  a  detached  cornu  of  the  uterus, 
containing  two  foetal  hares.  The  specimen  was  sub- 
mitted to  a  committee  consisting  of  Dr.  Ramsbottom 
and  Mr.  Simmonds.     These  gentlemen  furnished  a  very 

*    Trans.  Path.  Soc. ,  vol.  v.  p.  352  ;   1854. 
Z    2 


Fig.  114.— Intra-uterine 


Maceration  of  a  retained  Lamb. 


Rotation  of  the   Uterus.  389 

careful  report,  and  at  the  end  appended  the  following 
remarks  : — 

"Three  circumstances  are  especially  worthy  of  re- 
mark in  this  case  : — First,  there  were  no  signs  of  putrefac- 
tion ;  but  this  is  the  well-known  result  of  the  occlusion  of 
atmospheric  air.  Secondly,  that  both  foetuses  were  lying 
in  one  Fallopian  tube ;  consequently  both  ovules  had 
been  furnished  by  the  same  ovary,  whereas  usually  each 
cornu  uteri  is  impregnated,  if,  as  is  commonly  the  case, 
there  is  more  than  one  foetus.  And  lastly,  that  the  cyst 
containing  them  -was  quite  loose,  and  not  attached  to 
any  part  of  the  mother's  body.  Nevertheless,  there 
must  of  necessity  have  existed  a  connection,  and  the. 
probability  is  that  the  nipple-like  projection  was  the 
point  of  communication,  and  that  a  forcible  separation 
had  taken  place — most  likely  after  the  animal's  death, 
in  consequence  of  its  body  having  been  subjected  to 
rough  usage." 

It  might  be  argued  from  this  opinion  that  this  was  a 
case  of  tubal  gestation ;  but  Hutchinson,  in  describing 
the  specimen,  writes  : — 

"As,  in  the  hare,  the  uterus  itself  is  but  a  small 
pouch  in  the  vaginal  extremity  of  the  Fallopian  tube, 
and  as  gestation  is  normally  carried  on  partly  in  the 
latter,  it  is  idle  to  dispute  the  question  whether  the 
foetation  was  extra-uterine  or  not.  It  was  evidently 
72ormal.'''' 

It  is  clear  that  what  Mr.  Hutchinson  called  the 
Fallopian  tube  was  really  the  long  uterine  cornu  so 
natural  to  hares  and  rabbits,  and  was  not  a  case  of  tubal 
gestation  in  the  proper  sense. 

Detachment  of  the  uterine  cornua  has  been  reported 
in  the  ewe  by  Simmonds;*   and  Fleming!  quotes  four 

*   Veterinary  Record,  vol.  v.  p.  492  ;  1842. 
t    Veteritiary  Obstetrics,  p.  184. 


390  Tubal  Pregnancy. 

cases  described  by  Ercolani.  The  specimens — of  which 
the  following  is  a  brief  description — are  preserved  in  the 
museum  of  the  Bologna  University  : — 

1.  The  uterus  of  a  cow,  which  contained  in  one  of 
the  cornua  a  foetus  beyond  its  term,  and  in  the  other 
horn  such  a  quantity  of  mucus  that  it  would  be  difficult 
to  decide  which  was  the  larger  cornu.  The  uterus  is  com- 
pletely divided  at  the  cervix,  and  floats  in  the  abdominal 
cavity,  being  attached  only  by  the  broad  ligaments,  which 
are  thin  and  distended.  The  detached  portion  of  the 
uterus  has  a  globular  form,  and  its  perfectly  smooth 
surface  is  everywhere  covered  with  peritoneum.  Where 
the  separation  has  taken  place  the  organ  is  closed  by 
cicatricial  union  of  the  border  of  the  rupture.  The 
foetus  was  contained  in  the  right  cornu,  and  appeared  to 
have  lived  beyond  the  ordinary  period  of  gestation,  to 
judge  by  the  hoofs,  as  well  as  the  teeth  which  were 
cut.  The  foetus  was  curled  up,  and  formed  a  large 
discoid  body. 

2.  Cornu  of  the  uterus  of  a  pregnant  cow,  containing 
a  completely-developed  foetus  markedly  indurated.  This 
cornu,  perhaps  ruptured  during  parturition,  was  detached, 
and  hung  almost  free  in  the  abdomen,  while  the  rupture 
has  cicatrised,  and  there  is  formed  a  large  cyst,  every- 
w^here  closed,  and  containing  the  fcetus.  The  walls  of 
the  uterus  are  for  the  most  part  fibrous,  and  the  foetal 
envelopes  coriaceous.  Like  the  preceding  case,  it  was 
found  in  a  cow  which  had  been  slaughtered  by  the 
butcher.  The  cornu  fell  on  the  ground,  after  some 
fibrous  bands  which  attached  it  to  the  sub-lumbar  region 
had  been  cut  through. 

3.  The  uterus  of  sheep  arrived  at  the  termination  of 
pregnancy.  The  organ  had  been  torn  in  the  vicinity  of 
the  vagina,  and  remained  free  in  the  abdominal  cavity. 
In   this   instance,    also,   the   uterus    forms  a  completely 


Rotation  of  the   Uterus.  391 

closed  cyst,  which  contains  a  very  much  indurated  lamb. 
In  detaching  this  organ  an  irregular  cicatrix  was  seen, 
which  led  to  the  supposition  that  the  accident  was  due 
to  torsion  of  the  cervix. 

4.  Posterior  part  of  the  body  of  a  guinea-pig,  which 
shows  the  right  horn  of  the  uterus  detached  and  cica- 
trised at  the  point  of  separation.  This  horn,  which 
was  half  free,  was  filled  with  fluid  blood.  The  distension 
caused  by  the  blood  has  been  so  great  that  the  horn 
ruptured  in  the  middle,  and  the  fcetus  must  have  died 
from  haemorrhage. 

The  following  case  of  rotation  of  the  uterus  occurring 
in  a  cat,  quoted  by  Fleming,*  is  of  interest,  as  it  illustrates 
the  changes  produced  on  the  uterus  by  this  accident. 
They  are  similar  to  those  seen  in  rotated  ovarian  cysts : — 

"  Vivierf  had  a  fine  large  cat  two  years  old,  and  just 
dead,  brought  to  him.  A  few  hours  previously  it  had 
been  apparently  quite  well.  The  owner,  thinking  it  had 
been  poisoned,  wished  a  post  mortem  examination  to  be 
made.  On  incising  the  abdominal  parietes  he  was  sur- 
prised to  find  one  of  the  uterine  cornua  suddenly  escape 
from  the  opening.  This  cornu  was  deeply  congested ; 
indeed,  it  was  almost  of  a  violet  tint,  and  the  veins  were 
gorged  with  dark-coloured  blood.  The  other  cornu  was 
less  voluminous,  but  offered  the  same  lesions.  It  was 
evident  the  cat  was  pregnant. 

"  When  the  abdomen  was  completely  opened,  it  was 
discovered  that  the  uterus  had  ?nade  tivo  turns  upon  itself; 
the  cervix  presented  the  spiral  appearance  characteristic 
of  torsion  ;  the  broad  ligaments  were  intact,  and  had 
followed  the  uterus  in  its  revolution.  The  two  cornua 
being  opened  lengthways,  they  were  found  to  contain  a 

*    Veterinary  Obstetrics. 

f  Archives  Veterinaires,  Sept.,  1876,  p.  424. 


392  Tubal  Pregnancy. 

large  quantity  of  black  blood,  mixed  with  clots  ;  in  this 
fluid  were  five  fcetuses  (three  in  one  cornu  and  two  in  the 
other)  contained  in  their  membranes,  and  probably 
about  fifteen  days  old." 

We  have  now  to  consider  cases  of  retained  embryos, 
secondary  to  rupture  of  the  uterus. 

The  gravid  uterus  may  be  ruptured  from  traumatic 
causes  ;  with  this  we  are  not  concerned.  A  not  infre- 
quent cause  is  that  the  foetus  is  too  large  to  traverse  the 
maternal  passages,  and  the  uterus,  in  its  violent  con- 
tractions to  overcome  the  obstruction,  ruptures,  and  the 
foetus  or  foetuses  may  be  discharged  into  the  peritoneal 
cavity.  In  such  cases  the  foetus  may  be  found  in  the 
abdominal  cavity,  whilst  the  placenta  remains  in  the 
uterus  ;  in  others,  the  placenta,  as  well  as  the  foetus,  will 
be  extruded  into  the  peritoneal  cavity.  After  the  foetus 
escapes,  the  uterus  rapidly  contracts,  hence  a  slit,  which 
allows  a  full-sized  foetus  to  escape  from  the  uterine  cavity, 
rapidly  becomes  reduced  to  an  opening  of  very  small 
dimensions.  It  is  unusual  for  a  case  of  this  sort  to  give 
rise  to  any  difficulty  in  interpreting  the  course  of  events  ; 
the  majority  of  such  accidents  terminate  fatally.  In 
rare  instances  the  mother  survives. 

A  drawing  of  the  uterus  of  a  jackal,  in  which  the  rent 
occurred  on  the  dorsal  wall  of  the  vagina,  involving  also 
the  cervix  of  the  uterus,  is  shown  in  Fig.  115. 

Professor  Hamilton*  has  recently  recorded  a  case  of 
extra-uterine  gestation  in  a  cat.  The  following  is  his 
description  of  the  specimen  :— 

"  The  cat  from  which  I  derived  the  beautiful  speci- 
men now  in  my  possession  was  given  to  me  by  Professor 
Stirling  some  years  ago.  He  found  on  killing  the  animal 
that  the  abdomen  was  occupied  by  several  tumour  masses, 

*  J ouriial  of  Comparative  Medicine  and  Siirgeiy,  April,  1891. 


Rupture  of  the   Uterus. 


393 


and  judging  that  it  was  more  a  pathological  subject  than 
one  suited  for  physiological  purposes,  he  sent  it  over  to 
my  laboratory.  Being  busy  at  the  time,  and  not 
recognising  the  nature  of  the  tumours  from  the  fact  of 
their  being  so  bound  up  with  the  abdominal  organs,  I 
gave  directions  to  have  the  viscera  cut  out  and  placed  in 


Fig.  115. — Uterus  of  a  Jackal  which  ruptured  at  the  junction  of  Vagina 
and  Cervdx.     The  Foetuses  were  free  in  the  peritoneal  cavity. 


a  preservative  fluid.  To  my  astonishment,  on  coming  to 
examine  the  parts  some  time  afterwards,  I  found  that  each 
tumour  was  a  well-developed  kitten  lying  in  the  peritoneal 
sac.  I  had  the  whole  preparation  carefully  set  up,  and 
as  it  now  stands  the  description  of  it  is  as  follows  : — 

"  There  are  four  fully-developed  kittens  all  contained, 
along  with  their  adjuncta,  within  the  peritoneal  cavity. 
Three  of  these  are  amassed  in  a  somewhat  pyramidal 
conglomerate  measuring  7  by  6  cm.,  and  arising  from 
the  matting  together  of  the  parts  concerned  by  dense 


394  Tubal  Pregnancy. 

fibrous  adhesions.  The  kittens  lie  close  to  the  middle  of 
the  body  of  the  uterus,  and  are  rolled  up  in  a  portion  of 
the  great  omentum,  which  is  closely  stretched  over  the  sac 
in  which  each  is  contained.  Running  through  the  centre, 
and  so  forming  the  axis  of  the  tumour-like  structure,  are 
the  uterus  and  lower  part  of  the  intestine.  The  uterine 
horns  had  unfortunately  been  cut  off  close  to  their 
peripheral  extremities,  but  sufficient  of  them  remain  to 
show  that  they  are  free  from  anything  in  the  shape  of  a 
foetus — indeed,  so  far  as  one  can  judge,  they  seem  to  be 
in  their  virgin  state.  The  body  of  the  uterus  is  firmly 
clasped  by  the  tumour  mass,  and  its  channel  appears  to 
have  become  impervious,  apparently  from  the  pressure  of 
surrounding  parts.  Each  of  the  three  kittens  involved  is 
contained  in  a  single  membrane,  rough  internally,  but 
quite  smooth  externally.  The  exact  manner  of  attach- 
ment of  the  placentae  cannot  be  distinctly  traced,  owing  to 
the  fusion  of  the  component  elements. 

''  The  fourth  foetus  is  entirely  detached  from  the 
tumour  formed  by  the  other  three.  It  has  been  growing 
from  the  lower  edge  of  the  great  omentum,  and  appears 
to  be  the  longest,  measuring,  as  it  does,  between  12 
and  13  cm.  from  the  tip  of  the  nose  to  the  root  of  the 
tail.  It  is  coiled  up,  and,  like  the  others,  is  enclosed 
within  a  single  membrane,  rough  and  granular  internally, 
but  glabrous  on  the  exterior.  The  membrane  is  so  tough 
that  it  can  be  readily  handled  without  injury.  The  pla- 
centa is  situated  upon  the  interior,  or  rather  seems  to  form 
part  of  this  membrane.  The  area  occupied  by  it  is  some- 
what crescentic,  and  from  end  to  end  measures  from  2  J 
to  3  cm.  From  it  comes  off  what  looks  like  a  bunch  of 
fibrous  cords,  but  on  closer  inspection  each  of  these 
proves  to  be  an  umbilical  vessel.  Nearer  the  foetus  they 
are  twisted  into  a  rope-like  texture,  which  makes  a  couple 
of  coils  round  the  right  hind  limb,  immediately  above  the 


Rupture  of  the  Uterus.  395 

foot.      They  afterwards  penetrate  the  abdomen  in  the 
usual  situation,  the  abdominal  wall  being  perfectly  closed. 

"  The  omental  basis  to  which  the  placenta  is  attached 
is  constituted  by  a  few  of  the  islands  of  fat  naturally 
present  within  the  membrane.  The  loose  omental  trabe- 
cular tissue  for  some  distance  above  this  has  become 
adherent  to  and  bound  up  with  these  particles  of  fat  so 
as  to  constitute  a  solid  stump,  to  the  free  extremity  of 
which  the  placenta  is  united. 

"  There  is  an  entire  absence  of  anything  like  recent 
peritonitis,  and  the  only  evidence  of  its  having  existed 
formerly  is  in  the  localised  adhesions  whereby  the  three 
first  described  fcetuses  are  lashed  together  and  to  the  body 
of  the  uterus.  The  nutrition  of  the  mother,  like  that  of 
the  offspring,  was  excellent." 

In  describing  this  case  Professor  Hamilton  makes  re- 
marks on  the  subject  of  extra-uterine  gestation  in  general, 
and  comes  to  the  conclusion  that  "  the  only  explanation 
admissible  under  these  circumstances  is  that  the 
fecundated  ova  fell  either  from  the  ovary  directly,  or  from 
the  end  of  the  tube  into  the  abdominal  cavity,  and  took 
root  upon  the  parts  of  the  peritoneum  with  which  they 
came  in  contact." 

The  description  of  the  specimen  is,  however,  against 
this  explanation,  but  indicates  that  during  pregnancy 
rupture  of  the  uterus  occurred,  allowing  the  kittens  to  be 
extruded  into  the  peritoneal  cavity ;  as  this  is  an  air-tight 
chamber,  and  the  kittens  formed  no  intimate  connections 
with  the  intestine,  they  were  converted  into  the  con- 
glomerate masses  described  by  Professor  Hamilton.  The 
precise  condition  of  the  vagina  and  adjacent  parts  of  the 
uterus  could  not  be  ascertained,  because  "  the  uterine 
horns  had  unfortunately  been  cut  off  close  to  their  peri- 
pheral extremities."  Another  significant  sentence  is 
this  : — "  The  body  of  the  uterus  is  firmly  clasped  by  the 


396  Tubal  Pregnancy. 

tumour  mass,  and  its  channel  appears  to  have  become 
impervious,  apparently  from  the  pressure  of  the  sur- 
rounding parts."  It  is  not  beyond  the  bounds  of  proba- 
bility that  this  "  impervious  "  part  represents  the  situation 
of  the  original  rent  in  the  uterus  through  which  the 
kittens  were  ejected. 

Professor  Hamilton  writes  : — "  It  seems  one  of  the 
most  extraordinary  phenomena  in  nature  that  the  wall  of 
a  serous  cavity  should  thus  assume  functions  entirely 
foreign  to  it."  I  would  add:  There  is  no  7'easonahle  evidence 
to  lead  us  to  believe  that  such  an  event  occurs  either  in 
^omen  or  in  other  female  mammals. 

In  concluding  this  chapter  let  me  add  that  there  is 
no  accurate  or  trustworthy  description  of  a  case  of  tubal 
gestation  in  any  animal,  save  the  human  female,  on 
record.  That  this  form  of  gestation  occurs  I  have  no 
doubt,  but  it  awaits  demonstration. 


397 


CHAPTER  XXXVI. 

THE    DIAGNOSIS    OF    TUBAL    PREGNANCY. 

It  is  necessary  in  a  work  of  this  kind  to  devote  some 
space  to  the  consideration  of  what  is  called  pelvic 
lisematocele  before  discussing  the  diagnosis  of  tubal 
pregnancy  in  detail. 

In  its  general  sense  the.  expression  is  used  to  signify  a 
collection  of  blood  in  the  recto-vaginal  pouch  of  peri- 
toneum, or  between  the  layers  of  the  mesometrium. 
Blood  extravasated  in  any  quantity  into  the  peritoneal 
cavity  would  naturally  find  its  way  into  this  fossa.  There 
is  therefore  good  reason  for  adopting  the  suggestion  of 
Lawson  Tait,  "  that  the  phvcise  pe/vic  h(B?natocele  ought  to 
be  retained  to  cover  all  effusions  of  blood  which  have 
their  origin  in  the  pelvis." 

Pelvic  hsematoceles  are  of  two  kinds  :  the  blood  may 
be  effused  direct  into  the  peritoneal  cavity,  or  into  the 
connective  tissue  between  the  layers  of  the  mesometrium. 
The  first  variety  should  be  called  iiitra-peritoneal 
lisematocele,  and  the  second  lisematonia  of  the 
broad  ligament. 

The  first  systematic  account  of  this  important 
condition  was  published  by  Bernutz  and  Goupil,  and 
their  admirable  work  has  formed  the  basis  of  our  know- 
ledge of  the  pathology  of  pelvic  hsematocele. 

Bernutz  and  Goupil  arranged  the  causes  of  these 
pelvic  extravasations  under  five  headings  : — 

I.   Rupture  of  utero-tubar  varices. 


39 S  Tubal  Pregnancy. 

2.  Bloody  exhalations  from  the  pelvic  peritoneum. 

3.  Rupture  of  the  Fallopian  tube. 

4.  Difficult  menstrual  secretion. 

5.  From  metrorrhagia. 

A  study  of  the  various  cases  quoted  in  support  of  this 
classification  does  not  satisfy  me  that  it  is  sound.  The 
most  important  section  of  the  work  is  that  which  deals 
with  pelvic  haematoceles  occurring  in  extra-uterine 
pregnancies,  and  is  entirely  the  work  of  Goupil. 
Haemorrhage  arising  in  the  course  of  tubal  gestation  he 
arranges  under  five  causes,  and  suggests  a  sixth,  but  does 
not  actually  adopt  it. 

They  are  : — ■ 

1.  Rupture  of  a  dilated  utero-ovarian  vein. 

2.  Rupture  of  the  ovary. 

3.  Rupture  of  the  tube. 

4.  Rupture  of  the  cyst. 

5.  Hsemorrhage  within  the  cyst. 

The  sixth  cause  suggested  is  simple  haemorrhage 
from  the  Fallopian  tube. 

For  many  years  after  the  publication  of  Bernutz  and 
Goupil's  observations  our  knowledge  of  the  pathology  of 
pelvic  haematocele  received  but  little  addition.  Its 
clinical  importance  could  not  well  be  overlooked,  and 
text-books  deaHng  with  diseases  of  women  have,  since 
that  date,  devoted  space  to  its  consideration. 

One  of  the  most  important  facts  that  have  of  late 
years  been  demonstrated  in  connection  with  pelvic 
haematocele  is  that  nearly  all  the  extravasations  of  blood 
which  occur  in  the  recto-vaginal  fossa  (Douglas's)  or 
between  the  layers  of  the  broad  ligaments  are  due  to 
rupture  of  a  pregnant  tube.  For  the  simplification  of 
our  knowledge  in  this  direction  we  are  largely  indebted 
to  Lawson  Tait. 

On  becoming  acquainted  with  his  views,  it  seemed  to 


Pelvic  Hematocele,  399 

me  that  Tait  put  the  matter  too  strongly,  and  in  a  short 
paper  communicated  to  the  Medico-Chirurgical  Society 
I  urged  that  "  specimens  of  intra-peritoneal  haematocele, 
as  they  are  called,  have  been  recorded  and  shown  at 
societies  as  examples  of  ruptured  tubal  pregnancies,  but 
no  embryo  or  membranes  were  found.  I  am  strongly  of 
opinion  that  no  case  should  be  regarded  as  due  to  rup- 
tured tubal  pregnancy  unless  membranes  or  foetus,  or 
both,  are  forthcoming,  however  suggestive  the  clinical 
evidence." 

Since  that  paper  was  written,  not  only  have  I  come  to 
the  opinion  that  Tait  is  right  in  insisting  that  most  pelvic 
haematoceles  are  secondary  to  tubal  pregnancy,  but  my 
observations,  that  many  impregnated  ova  which  escape 
from  the  tube,  either  by  rupture  or  abortion^  are  in  the 
condition  of  moles,  have  furnished  additional  means  of 
recognising  the  nature  of  the  case. 

Returning  to  the  classification  of  Bernutz  and  Goupil, 
we  may  at  once  dispose  of  groups  2  and  4,  "bloody 
exhalations  from  the  pelvic  peritoneum,"  and  "  difficult 
menstrual  secretion,"  as  meaningless ;  group  3,  or 
"haemorrhage  from  rupture  of  the  Fallopian  tube,"  is 
covered  by  the  second  section,  or  haematoceles  secondary 
to  extra-uterine  pregnancy ;  group  i,  "  Rupture  of  utero- 
tubar  varices,"  and  group  5,  "  haematocele  from 
metrorrhagia,"  are  causes  believed  in  by  most  obste- 
tricians, Intra-peritoneal  haematocele  or  a  haematoma 
from  such  a  cause  must  be  very  rare,  and  opportunities 
for  dissecting  such  cases  have  never  occurred  to  me.  To 
these  we  must  add  haemorrhage  into  the  broad  ligament 
after  removal  of  a  cyst  from  between  its  layers,  or  into  the 
peritoneum  from  the  slipping  of  an  ill-applied  ligature 
after  operations  on  the  pelvic  viscera. 

With  regard  to  haematoceles  secondary  to  extra- 
uterine   gestation,    we    may   arrange    them    under   two 


400  Tubal  Pregnancy. 

headings,  instead  of  the  five  or  six  adopted  by  Bernutz 
and  Goupil.     The  classification  would  be  as  follows  : — 

1.  Rupture  of  blood-vessels  lying   between  the  layers 

of  the  broad  ligament. 

2.  Haemorrhage  secondary    to    surgical    procedures 

on  the  ovary  or  tubes. 

3.  Regurgitation  from  the  uterus  into  the  tubes. 

4.  Rupture  of  a  gravid  Fallopian  tube. 

5.  Tubal  abortion. 

It  is  with  the  last  two  of  this  series  that  we  are  con- 
cerned. 

The  symptoms  of  tubal  g^estatioii  vary  con- 
siderably according  to  the  degree  to  which  gestation  has 
advanced  ;  it  will  therefore  be  necessary  to  deal  with  it 
in  the  following  stages  :— 

1.  Before  primary  rupture  or  abortion. 

2.  At  the  time  of  primary  rupture  or  abortion. 

3.  From  the  date  of  primary  rupture  to  term. 

4.  After  term. 

Before  proceeding  to  discuss  the  signs  which  occur 
during  each  of  these  stages,  it  will  be  necessary  to  point 
out  that  the  patient  is  sometimes  aware  that  she  is  preg- 
nant ;  in  very  many  cases  she  is  not  aware  of  the  fact, 
and  the  practitioner  is  often  deceived  by  the  absence  of 
the  usual  signs  of  gestation,  viz.  fulness  of  the  breasts 
and  amenorrhoea.  The  breast  signs  are  very  variable 
in  tubal  gestation  ;  in  many  cases  they  are  absent  even 
when  the  pregnancy  has  gone  on  to  the  fifth  month  ;  in 
others  the  signs  of  pregnancy  are  as  clear  and  as  marked 
as  in  normal  gestation.  In  one  of  my  cases  milk  was 
present  in  one  breast  only,  and  that  was  on  the  same  side 
as  the  gravid  tube.  Speaking  generally,  the  absence  of 
the  usual  signs  of  pregnancy  do  not  negative  the  existence 
of  tubal  gestation  ;  on  the  other  hand,  their  presence  is 
valuable,  and  may  lead  to  a  correct  diagnosis. 


The  Signs  of  Rupture.  401 

Before  primary  rupture. — Gravid  tubes  have  in  a 
few  instances  been  removed  before  primary  rupture  or 
abortw?i,  but  in  nearly  all  the  recorded  instances  the 
operation  was  undertaken  for  the  purpose  of  removing 
diseased  tubes ;  examination  of  the  parts  after  removal 
has  revealed  the  fact  that  they  were  gravid. 

Dr.  Herman  in  one  undoubted  case  diagnosed  the 
existence  of  tubal  pregnancy  before  rupture,  and  his  diag- 
nosis was  completely  confirmed  at  the  operation.  The 
case  was  interesting,  as  he  had  previously  operated  on 
the  patient  for  tubal  gestation.  The  details  of  this  im- 
portant case  are  given  on  page  367. 

Primary  rapture.— In  tubal  gestation  the  sac 
ruptures  or  abortio7i  occurs,  if  the  pregnancy  progresses, 
at  some  period  before  the  twelfth  week ;  the  effect  upon 
the  patient  depends  on  the  seat  of  rupture.  When  the 
rupture  takes  place  between  the  layers  of  the  broad  liga- 
ment, the  symptoms  will,  as  a  rule,  be  less  severe  than 
when  the  tube  bursts  into  the  peritoneum,  because  the 
pressure  exercised  by  the  blood  extravasated  into  the 
tissues  of  the  broad  ligament  tends  to  check  haemorrhage, 
whereas  the  peritoneum  will  hold  all  the  blood  the 
patient  possesses,  and  yet  produce  no  hccmostatic  effect 
in  the  form  of  pressure. 

The  signs  of  intra-peritoneal  rupture  are  those 
characteristic  of  internal  haemorrhage.  The  patient  com- 
plains of  "  a  sudden  feeling  as  if  something  had  given 
way,"  and  this  is  followed  by  general  .pallor,  faintness, 
sighing  respiration,  depression  of  temperature,  rapid  and 
feeble  pulse,  usually  vomiting  and  in  some  cases  death 
ensues  in  a  few  hours. 

Should  the  patient  recover  from  the  shock,  she  will 
often  state  that  she  suspected  herself  to  be  pregnant. 
The  symptoms  of  rupture  are  often  accompanied  by 
haemorrhage  from  the  vagina,  and  shreds  of  decidua  will 

A  A 


40  2  Tubal  Pregnancy. 

be  passed,  so  that  the  case  resembles  in  many  points,  and 
is  sometimes  mistaken  for,  early  abortion. 

The  rapidity  with  which  the  rupture  of  a  gravid  tube 
will  sometimes  destroy  life  has  caused  more  than  one 
writer  to  describe  this  accident  "  as  one  of  the  most 
dreadful  calamities  to  which  women  can  be  subjected  "  ; 
indeed,  it  is  so  rapidly  fatal  in  some  instances  that  more 
than  one  case  is  on  record  in  which  death  has  been 
attributed  to  poisoning,  until  dissection,  instituted  in 
many  instances  by  the  coroner,  has  revealed  the  true 
cause  of  death.  It  will  be  useful  to  illustrate  this  by 
briefly  describing  a  few  cases. 

In  1882  Mr.  Daly  exhibited  to  the  Obstetrical  Society, 
London,  a  specimen  of  extra-uterine  gestation.  The  pa- 
tient, who  believed  herself  to  be  two  months  pregnant, 
was  .seized  immediately  after  dining  with  violent  pain  in 
the  abdomen,  became  blanched  in  the  face,  covered  v/ith 
cold  sweat,  and  passed  into  a  state  of  collapse,  from  which 
she  scarcely  raUied,  and  died  on  the  fourth  day.  At  the 
post  mortem  examination  the  tubal  gestation  sac  was 
found  on  tne  right  side,  this  had  ruptured  and  two  pints 
of  blood  were  found  in  the  abdomen.  There  was  no  trace 
of  peritonitis. 

In  the  discussion  that  followed  the  reading  of  this 
case,  Dr.  Chahbazian*  mentioned  the  case  of  an  English 
actress  who  died  in  Paris  in  the  following  circum- 
stances : — She  was  taking  an  ice  in  a  cafe  of  the  Bois  de 
Boulogne,  when  suddenly  she  fell  down  dead.  Poisoning 
being  suspected,  her  corpse  was  sent  to  the  Morgue,  and 
at  the  necropsy  he  examined  the  stomach  and  the  diges- 
tive organs  for  poison.  No  trace  of  poison  was  found, 
but  incidentally  he  discovered,  with  those  who  assisted 
him,  the  sac  of  an  extra-uterine  foetation  which  had 
ruptured. 

*   Trans.  Obstet.  Society,  Loudoft,  vol,  xxiv.  p.  157. 


The  Signs  of  Rupture.  403 

It  is  rarely  they  die  so  quickly  as  in  the  case  just 
mentioned.     The  following  case  was  unusually  rapid. 

A  married  woman,  the  mother  of  several  children, 
believed  herself  to  be  in  good  health  and  had  no  sus- 
picion of  pregnancy,  ate  a  large  quantity  of  mussels  for 
supper,  and  retired  to  bed.  In  the  course  of  the  night  she 
vomited,  and  whilst  vomiting  was  suddenly  seized  with 
severe  and  violent  pain  in  the  abdomen.  Dr.  Clegg,  of 
Stratford,  was  summoned  ;  from  the  history  of  the  case,  and 
the  collapsed  condition  of  the  patient,  he  suspected  she 
had  been  poisoned.  In  twelve  hours  the  patient  died. 
Dr.  Clegg,  on  a  coroner's  warrant,  made  a  post  inorteni 
examination,  and  found  a  gravid  Fallopian  tube.  The 
embryo  corresponded  to  the  eighth  week  of  gestation. 
The  sac  had  ruptured  in  two  places,  the  blood  escaping 
in  large  quantity  into  the  peritoneal  cavity.  The  speci- 
men is  preserved  in  the  museum  of  the  London  Hospital, 
and  a  drawing  of  the  parts  is  given  in  Fig.  116. 

From  an  analysis  of  many  careful  and  accurate 
records  of  this  accident,  it  would  seem  that  the  most 
rapidly  fatal  cases  are  those  in  which  the  ovum,  is  lodged 
in  the  uterine  section  of  the  tube — tubo-uterine  gestation. 
Death  may  ensue  in  a  few  hours. 

A  striking  example  of  this  was  recorded  by  Mr.  C.  H. 
Roper : — * 

A  woman  thirty-two  years  of  age,  the  mother  of  two 
children,  was  suddenly  seized  whilst  in  bed  with  severe 
abdominal  pain,  followed  by  diarrhcea  and  vomiting. 
The  doctor  was  summoned,  and  he  found  the  patient's 
skin  cool  and  moist,  the  respiration  and  temperature 
normal,  and  the  pulse  good.  Ten  hours  later  she  was 
in  a  condition  of  collapse,  and  twelve  "hours  after  the 
onset  of  the  symptoms  she  died.       At  the  post  mortem 

*   Trans.  Obstet.  Soc,  vol.  xxiv.  p.  227. 
A  A    2 


404 


Tubal  Pregnancy. 


exaaiiiiation  the  abdominal  cavity  was  found  to  contain 
a  large  quantity  of  blood-clot  and  bloody  fluid.     Floating 


VILLI 


YOLK-SAC 


A.  OSTIUM 


Fig.  1 16. — Gravid  Fallopian  Tube,  which  ruptured  and  caused  death  in 
twelve  hours.     (Museum  of  the  London  Hospital.) 


in  this  was  an  embryo,  corresponding  to  the  -second 
month  of  development,  enveloped  in  its  membranes. 
At  the  upper  part  of  the  uterus  a  rupture  was  detected 
large  enough  to  admit  three  fingers. 


The  Signs  of  Rupture.  405 

This  specimen  was  dissected  subsequently  by  Mr. 
Alban  Doran,  and  found  to  be  an  example  of  tubo- 
uterine  gestation  (Fig.  104). 

Fortunately,  death  is  not  always  so  sudden,  even  when 
the  rupture  is  intra-peritoneal,  as  the  following  cases 
prove  : — 

A  woman  thirty-seven  years  of  age  came  under  my 
care  in  the  Middlesex  Hospital.  She  had  been  twice 
married.  Her  matrimonial  life  extended  over  seventeen 
years,  and  she  had  never  been  pregnant.  Five  weeks 
before  admission,  patient  was  seized  with  sudden  violent 
pain  in  the  abdomen.  Dr.  Clegg,  of  Stratford,  was  sent 
for  and,  on  arriving,  found  the  woman  collapsed.  Slowly 
she  re-acted;  and  refused  to  allow  any  vaginal- examination 
to  be  made.  In  the  course  of  a  few  days  a  swelling 
appeared*  on  the  right  side  of  the  abdomen.  At  the 
end  of  five  weeks  she  was  sent  to  me  at  the  Middlesex 
Hospital. 

On  admission  I  found  a  swelling  occupying  the  right 
iliac  fossa,  extending  upwards  to  the  costal  arch,  and 
inwards  as  far  as  the  middle  line.  The  uterus  was  nor- 
mal in  position,  and  the  sound  entered  three  inches. 
The  right  side  of  the  recto-vaginal  pouch  was  occu- 
pied by  an  ill-defined  swelling,  firm  to  the  touch  ;  a 
rounded  movable  nodule,  of  the  bigness  of  a  Tangerine 
orange,  lay  behind  the  uterus.  No  breast  signs  or  history 
of  vomiting.  There  was  great  tenderness  over  the  abdo- 
minal aspect  of  the  tumour.  During  the  next  twelve 
days  the  temperature  ranged  from  99°  in  the  morning 
to  101°  in  the  evening. 

On  September  6th  (twelve  days  after  admission)  I 
opened  the  abdomen,  and  came  upon  a  quantity  of 
putrid,  dark-coloured  blood-clot  filling  the  pelvis  and 
right  iliac  fossa,  and  extending  upwards  to  the  liver.  A 
gestation  sac  was  found  in  the  right  Fallopian  tube ;  an 


4o6  Tubal  Pregnancy. 

apoplectic  ovum,  and  the  head  of  an  embryo  of  about 
the  eighth  week  among  the  blood-clot. 

In  this  case  the  patient  had  survived  an  intra- 
peritoneal rupture  nearly  seven  weeks.  She  recovered 
from  the  operation.*  The  amount  of  blood  extravasated 
in  this  case  was  very  great,  and  extended  from  the  pelvis 
along  the  right  side  of  the  abdomen  to  the  liver.  The 
parts  removed  in  this  case  are  sketched  in  Fig.  95. 

The  museum  of  St.  George's  Hospital  contains  a 
specimen  the  history  of  which  is  exceedingly  instructive. 
It  is  the  uterus.  Fallopian  tubes,  and  broad  ligaments. 
The  left  Fallopian  tube  is  distended  near  its  uterine  end, 
and  contains  an  early  embryo.  The  gestation  sac 
had  ruptured  on  its  posterior  aspect  and  blood-clot 
projects  from  the  opening.  The  uterus  is  enlarged,  and 
its  cavity  contains  a  ragged  decidua  (Fig.  117). 

The  patient  was  thirty-five  years  of  age  ;  she  had  had 
twelve  children  :  the  last  in  1883.  She  was  in  good 
health  on  August  i6th,  1886,  when  she  started  from 
Cowes  (Isle  of  Wight)  for  London.  She  was  suddenly 
seized  whilst  in  the  train  with  acute  abdominal  pain  and 
vomiting.  On  August  i8th  she  was  admitted  into  St. 
George's  Hospital  in  a  state  of  collapse  :  the  urine  had 
been  suppressed  for  twenty  hours  ;  the  belly  was  tense 
and  tender.     She  died  nine  hours  after  admission. 

It  is  worth  noticing  that  in  many  cases  the  acute 
signs  of  rupture  occur  soon  after  the  patient  retires  to 
bed.  It  has  often  suggested  itself  to  me  that  in  some 
of  these  cases  the  determining  cause  was  probably  sexual 
congress.  In  the  case  briefly  described  on  page  310  the 
symptoms  set  in  immediately  after  this  act  was  vigor- 
ously indulged  in  subsequent  to  a  long  abstinence. 

It  is  not  difficult  to  prove  that  a  pregnant  Fallopian 

*  Medico-Chir.  Transactions,  vol.'  Ixxiii.  p.  55. 


2' HE  Signs  of  Rupture. 


407 


tube  may  rupture  into  the  peritoneal  cavity,  and  the 
hemorrhage  be  so  small  as  to  give  rise  to  only  slight 
symptoms.     In  August,  1886,  I  removed  by  abdominal 


DECIDUA         EMBRYO 


GESTATIOM    SAC 


Fio-    117  —Gravid  Tube.     The  gestation  sac  ruptured,  and  caused  death  in 
"*      about  forty-eight  hours.     (Museum,  St.  Georges  Hospital.) 


section  the  tubes  and  ovaries  from  a  woman  aged  twenty- 
five  years.  She  had  been  treated  for  many  weeks  by  rest 
and  medicine  for  what  w^as  supposed  to  be  chronic 
inflammation  of  the  Fallopian  tubes,  and  a  hard  rounded 
swelling  was  easily  detected  on  the  left  side  of  the  uterus. 
The  symptoms  had  come  on  insidiously ;  there  had 
never  been  any  sudden  pain  or  arrest  of  menstruation. 
On  drawing  up  the  left  uterine  appendages,  they  were 
found  adherent  to  a  large  fold  of  omentum,  containing 


4o8  Tubal  Pregnancy. 

blood-clot  and  an  ounce  of  fluid  blood.  The  omentum, 
tube,  and  ovary,  with  the  adjacent  portion  of  the  meso- 
metrium,  were  removed.  The  ovary  contained  some 
enlarged  follicles,  and  it  was  thought  that  one  of  these 
had  ruptured  and  furnished  the  hnemorrhage.  The  speci- 
men puzzled  me  at  the  time,  and  was  carefully  preserved. 
Two  years  later  I  re-examined  the  parts,  and  found  a 
rupture  in  the  Fallopian  tube,  near  the  abdominal  ostium. 
Lying  snugly  in  the  fold  of  omentum  adherent  to  the 
tube  was  a  rounded  mass  of  laminated  clot,  and  in  this 
a  tubal  mole  as  big  as  a  cob-nut.  One  part  of  its  circum- 
ference looked  ragged,  and  on  teasing  some  of  the  frag- 
ments in  glycerine,  and  examining  them  microscopically, 
they  were  found  to  be  typical  chorioni  villi.  The  parts 
are  shown  of  nearly  natural  size  in  Fig.  ii8.  It  then  be- 
came clear  that  the  tube  had  been  gravid.  The  ovum 
had  been  converted  into  a  mole  followed  by  rupture 
of  the  gestation  sac  at  about  the  third  week.  The  date 
of  the  rupture  could  not  be  fixed  with  certainty,  bat  I 
knew  from  physical  signs  that  this  clot  had  occupied  the 
omentum  for  many  weeks  before  the  operation.  The 
fact  that  this  mole  and  the  surrounding  clot  were,  for  so 
many  weeks,  tolerated  by  the  peritoneum  assists  us  in 
comprehending  that  when  an  apoplectic  ovum  is  dis- 
charged from  the  Fallopian  tube  and  lodged  between  the 
layers  of  the  mesometrium,  it  becomes  sequestrated,  and 
in  many  cases  causes  no  further  trouble. 

In  tubal  abortion  and  primary  extra-peri- 
toneal rupture  the  symptoms  are  not  so  urgent,  and 
may  be  misleading. 

Our  knowledge  of  the  leading  symptoms  of  tubal 
abortion  is  very  limited.  The  following  are  the  chief 
points  in  the  clinical  history  of  the  first  case  which  came 
under  my  notice  : — 

Mrs.  N ,  aged  26  years,  married,  and  mother  of 


The  Signs  of  Rupture. 


409 


two  children,  the  youngest  being  six  years  of  age.  One 
morning,  whilst  engaged  with  her  domestic  duties,  she 
was  suddenly  seized  with  severe  abdominal  pain,  accom- 
panied by  a  discharge  of  blood  from  the  uterus.  The 
catamenia  had  been  perfectly  regular  for  four  years,  and 


Fig.  118. — Gravid  Fallopian  Tube  which  has  ruptured.     The  apoplectic 
ovum  was  caught  and  sequestrated  in  a  fold  of  omentum. 


there  was  not  the  slightest  suspicion  of  pregnancy. 
There  was  no  swelling  of  the  abdomen ;  the  left  breast 
contained  milk ;  there  was  no  difficulty  with  the  bladder 
or  urine.  On  examination  through  the  vagina  a  rounded 
mobile  tumour  could  be  made  out  on  the  right  side,  and 
a  smaller  but  less  defined  and  very  tender  swelling  on  the 
left.  Three  days  later  the  patient  was  examined  under 
chloroform,  and  a  consultation  held  upon  the  case.     In 


41  o  Tubal  Pregnancy. 

consequence  of  the  manipulations  the  patient's  tempera- 
ture rose  during  the  next  twenty-four  hours  to  103°,  the 
pulse  was  rapid  and  feeble,  and  she  complained  of  great 
pain.  The  abdomen  was  then  opened,  and  the  intestines 
were  found  floating  in  blood.  The  abdominal  ostium  of 
the  left  tube  was  widely  open ;  the  tube  contained  blood- 
clot  and  a  small  body  that  was  afterwards  proved  to 
be  an  early  apoplectic  ovum  {see  page  328  and  Plate  V.). 
The  tumour  on  the  right  side  proved  to  be  an  oophoritic 
cyst. 

In  extra-peritoneal  rupture — that  is,  when  the 
tube  bursts  so  that  the  blood  is  extravasated  between  the 
layers  of  the  broad  ligament — the  symptoms  resemble 
intra-peritoneal  rupture,  but  as  a  rule  are  not  so  severe, 
and  the  signs  of  shock  j)ass  off  quicker.  On  examining 
by  the  vagina,  a  rounded  ill-defined  swelling  occupies  one 
or  other  broad  ligament ;  when  the  effused  blood  is  large 
in  amount  the  uterus  will  be  pushed  to  the  opposite  side. 
When  the  bleeding  takes  place  into  the  left  broad  liga- 
ment it  will  sometimes  extend  backwards  under  the  peri- 
toneum, and  invade  the  connective  tissue  around  the 
rectum,  so  that  when  the  exploring  finger  is  introduced 
into  the  rectum,  a  semicircle,  sometimes  a  ring,  of 
swollen  tissue  will  be  felt  encircling  the  gut. 

The  escape  of  decidual  membrane  from  the  uterus 
accompanied  by  blood  is  also  an  important  and  fairly 
constant  sign.  Occasionally  it  will  be  necessary  to  pass 
a  sound  into  the  uterus ;  the  cavity  of  this  organ  will  be 
found  slightly  enlarged  when  the  tube  is  gravid  and  the 
OS  is  invariably  patulous. 

The  greatest  difficulty  in  these  cases  is  to  be  sure  that 
the  rupture  is  purely  extra-peritoneal.  In  a  {^^n  cases 
the  rupture  may  also  involve  the  peritoneal  as  well  as  the 
uncovered  portion  of  the  tube.  In  one  of  my  cases 
the  bleeding  was  at  first  extra- peritoneal,   but  the  broad 


The  Signs  of  Tubal  Pregnancy.  411 

ligament  became  so  rapidly  distended   that   the  blood 
burst  through  into  the  peritoneum. 

Not  infrequently  after  primary  extra-peritoneal  rup- 
ture the  symptoms  of  shock  pass  off,  and  the  embryo 
continues  its  development ;  in  many  instances  in  which 
the  patients  believe  themselves  pregnant,  the  haemorr- 
hages from  which  they  suffer  and  the  signs  indicative  of 
the  primary  rupture  may  merely  cause  temporary  incon- 
venience. As  the  embryo  grows  the  abdomen  increases 
in  size,  but  the  enlargement  differs  from  ordinary  uterine 
gestation  in  that  it  is  lateral  instead  of  median. 

From  the  third  month  onwards  the  leading'  signs 
of  tubal  gestation  may  be  summarised  thus  : — ■ 

(i)  Aniejiorrhoea  is  occasionally  found  ;  frequently 
there  is  haemorrhage  from  the  uterus,  occurring  at  irregular 
intervals,  accompanied  by  the  escape  of  decidual  mem- 
brane. This  last  is  a  valuable  diagnostic  sign.  It  is  even 
more  valuable  if  the. patient  has  missed  one  or  two  periods. 

(2)  There  may  or  may  not  be  milk  in  the  breasts. 
Its  presence  is  a  valuable  indication.  From  its  absence 
nothing  can  be  inferred. 

(3)  The  uterus  is  slightly  enlarged  ;  the  os  is  usually 
soft,  as  in  normal  pregnancy,  and  patulous. 

(4)  A  large  and  gradually  increasing  swelling  to  one 
side  and  behind  the  uterus.  Occasionally  the  foetal 
heart  can  be  heard,  and  in  advanced  cases  the  outlines 
of  the  foetus  may  be  distinguished. 

(5)  When  a  woman  in  whom  the  existence  of  tubal 
gestation  is  suspected  is  suddenly  seized  with  collapse, 
and  all  the  signs  of  internal  bleeding,  it  is  indicative  of 
rupture  of  the  gestation  sac. 

(6)  Tubal  pregnancy  is  very  apt  to  occur  after  long 
intervals  of  sterility. 

In  spite  of  all  the  risks  that  beset  the  life  of  an 
extra-uterine  child  and  that  of  its  mother,  the  pregnancy 


412  Tubal  Pregnancy. 

may  go  to  term.  Then  a  remarkable  series  of  events 
ensues. 

{a)  Paroxysmal  abdominal  pains  come  on,  resembling 
those  of  natural  labour,  accompanied  by  a  discharge  of 
blood  and  mucus  from  the  uterus  resembling  the  "show," 
and  the  os  uteri  dilates. 

{b)  This  unavailing  labour  may  last  a  few  hours  or 
days  (it  is  stated  to  have  lasted  for  weeks  in  some 
patients),  and  then  subside. 

{c)  The  mammae  may  continue  to  secrete  milk  for 
several  weeks. 

These  signs  sometimes  pass  away,  the  liquor  amnii  is 
absorbed,  the  swelling  diminishes  in  size,  and  the  retained 
foetus  causes  no  trouble.  In  the  majority  of  cases  suppura- 
tion takes  place  in  the  sac,  the  foetus  decomposes,  and  frag- 
ments of  its  tissues  are  discharged  through  sinuses  in  the 
groin,  abdomen,  vagina,  rectum,  or  bladder.  It  should  be 
remembered  that  the  onset  of  labour  may  rupture  the  sac. 

The  diagnosis  of  tubal  gestation  is  often  extremely 
simple,  but  in  many  cases  it  is  surrounded  by  many  diffi- 
culties. The  conditions  with  which  it  is  most  frequently 
confounded  may  be  briefly  mentioned,  with  reference  to 
reported  cases. 

1.  Uterine  gestation. — In  1891  Dr.  Griffith*  com- 
municated to  the  Obstetrical  Society  details  of  a  case  in 
which  a  pregnant  woman  came  under  his  care  ;  she  was 
supposed  to  have  twins,  one  intra-  and  the  other  extra- 
uterine. It  ultimately  turned  out  that  the  patient  was 
pregnant,  and  what  was  supposed  to  be  the  head  of  an 
extra-uterine  child  was  a  large  fibroma  of  the  ovary, 
obstructing  labour. 

2.  Tubal  gestation  in  the  broad  ligament  stage  may  be 
mistake?!  for  an  ovarian  cyst.     Doranf  mentioned  a  case 

*   Trans.  Obstct.  Soc,  London,  vol.  xxxiii.  p.  140. 
f  Ibid.,  vol.  xxxiii.  p.  156. 


Differential  Diagxosis.  413 

of  this  kind  in  which  no  operative  treatment  was  carried 
out;  at  ihe  post  mortem  examination  the  true  nature  of 
the  case  was  ascertained. 

Extra-uterine  gestation  in  the  broad  hgament  stage 
has  been  several  times  mistaken  for  a  gangrenous  myoma 
or  sarcoma,  even  when  the  parts  have  been  exposed  by 
abdominal  section.  This  is  a  serious  error,  as  the 
operator,  instead  of  opening  the  sac,  attempts  to  remove 
the  tumour,  usually  with  a  fatal  result. 

An  ovarian  cyst  may  be  present  as  ivell  as  a  gravid 
tube*  I  once  operated  on  a  case  in  which  the  left 
.tube  was  gravid,  and  an  ovarian  cyst  existed  on  the 
right  side. 

A  retj'ovei'ted  gravid  uterus  has  been  a  source  of  error. 
Retention  of  urine,  so  characteristic  of  this  condition,  is 
occasionally  produced  when  the  embryo  occupies  the 
broad  ligament,  accompanied  by  much  haemorrhage.  On 
the  other  hand,  extra-uterine  gestation  has  been  mistaken 
for  retroversion  of  a  gravid  uterus.  Dr.  Godsonf  relates 
a  case  which  occurred  in  a  woman  who  had  been  married 
thirteen  years.  A  year  after  marriage  she  had  one  child. 
She  remained  sterile  for  twelve  years,  and  then  became 
pregnant.  On  account  of  inability  to  pass,-  she  was  ad- 
mitted into  St.  Bartholomew's  Hospital,  and  an  ineffectual 
attempt  made  to  replace  what  was  supposed  to  be  a 
retroverted  uterus.  She  was  subsequently  discharged. 
Eventually  Dr.  Carter  removed  an  extra-uterine  foetus  by 
abdominal  section. 

Gestation  in  one  horn  of  a  bicor?iuate  uterus  should  be 
remembered. — The  relation  of  cornual  to  tubal  pregnancy 
is  so  important  that  the  chief  facts  concerning  this  condi- 
tion are  related  in  chapter  xxxii. 

*   Trans.  Obstet.  Soc. ,  London,  vol.  xxxii.   p.  342.      See  also  Edis 
Journ.  of  the  Brit.  Gyn.  Soc,  vol.  v.  p.  57. 
f  Proc.  Med.  Soc. ,  London,  vol.  vii.  p.  390. 


414  Tubal  Pregnancy. 

The  early  stages  of  tubal  gestation  are  most  likely  to 
be  confounded  with  hydro-  <yViA pyo-salpinx^sjuall  ovarian 
cysts ^  and  pelvic  cellulitis. 

At  the  time  of  rupture  the  symptoms  may  mimic 
many  conditions,  such  as  intussusception  and  other  forms 
of  intestinal  obstruction,  perforation  of  the  stomach  or 
intestines,  rupture  of  an  aneurism,  acute  axial  rotation  of 
an  ovarian  cyst,  abortion,  even  renal  or  biliary  colic.  To 
give  details  of  cases  illustrative  of  these  errors  would  be 
tedious,  but  such  have  been  repeatedly  made. 

Sinclair  Stevenson*  reported  a  case  of  spurious  preg- 
nancy si7Jiulati7ig  ectopic  gestation  of  the  fourth  months  in 
which  there  was  amenorrhoea.  So  strongly  marked  were 
the  signs  of  tubal  pregnancy  that  the  abdomen  was 
opened  ;  instead  of  pregnancy,  a  small  cyst  of  the  ovary 
was  found. 

It  is  well  known  that  in  several  instances  the  abdo- 
men has  been  opened  under  the  impression  that  the 
patients  were  suffering  from  tubal  pregnancy,  but  nothing 
abnormal  was  found.  Normal  pregnancy  has  been  mis- 
taken for  extra-uterine  gestation ;  the  abdomen  was 
opened,  the  fcetus  extracted,  and  the  uterus  excised 
before  the  error  was  discovered. 

In  very  many  instances  abdominal  section  has  been 
undertaken  to  remove  supposed  ovarian  tumours,  dilated 
tubes,  and  the  like,  but  the  supposed  tumours  have  turned 
out  to  be  gestation  sacs.  This  is  no  reflection  on  the 
surgeon,  and  more  than  justifies  the  interference.  When 
a  surgeon  opens  the  abdomen  to  remove  a  tumour  sup- 
posed to  exist  within,  and  finds  nothing  abnormal,  it  re- 
calls the  following  sentences  relating  to  phantom  tumour, 
expressed  in  Matthew  Duncan'sj  characteristic  style : — 

*   Trans.  Obsfet.  Soc,  London,  vol,  xxxii.  p.,  216^ 
f  Perimetritis  and  Parametritis,  p.  58. 


Differential  Diagnosis.  415 

"  These  cases  are  improperly  described  as  tumours  of 
any  kind.  There  is  only  fulness  of  the  abdomen.  The 
whole  disease  is  generally  quite  as  much  a  phantom 
of  the  brain  of  the  patient  and  of  the  physician  as  a 
tumour,  of  whatever  designation,  of  the  belly." 

Uterine  myomata  and  broad  ligament  tumours  simu- 
late extra-uterine  gestation, 

Skene  Keith*  has  briefly  mentioned  a  case  in  which 
his  father  performed  abdominal  section,  expecting  to  find 
a  "  fibroid  tumour,"  but  on  cutting  into  it,  a  foetus,  which 
had  been  dead  nearly  two  years,  was  found. 

Thornton  and  others  have  dissected  out  the  sac, 
under  the  belief  that  they  were  dealing  with  tumours. 

On  the  other  hand,  operations  have  been  undertaken 
under  the  impression  that  the  patients  were  victims  to 
advanced  extra-uterine  pregnancy,  but  tumours  have  been 
found  instead.! 

Dr.  John  Williams t  writes  :  "  I  once  saw  a  sweUing 
which  appeared  to  be  a  small  ovarian  cyst  aspirated  ;  it 
proved  afterwards  to  be  the  placenta  in  a  case  of  extra- 
uterine gestation." 

*  Obstet.   Trans..,  Edin.,  vol.  x.  p.  92. 

f  Meadows  has  recorded  a  striking  instance  of  this :    Trans.  Obstet. 
Soc,  London,  vol.  xv.  p.  145. 
X  Ibid.,  vol.  xxix.  p.  490. 


4i6 


CHAPTER    XXXVII. 

THE    TREATMENT    OF    TUBAL    GESTATION. 

The  admirable  results  which  have  followed  the  treatment 
of  tubal  pregnancy  by  abdominal  section  have  served 
to  establish  this  method  on  as  secure  a  footing  as 
ovariotomy. 

Methods  formerly  advocated,  such  as  killing  the  foetus 
by  injecting  drugs  into  its  body,  or,  more  recently,  by 
electricity  and  similar  unsurgical  procedures,  are  of  such 
an  unsatisfactory  character  that  they  will  not  be  con- 
sidered. 

The  risks  and  difficulties  of  an  operation  for  tubal 
pregnancy  depend  mainly  upon  the  extent  to  which 
gestation  has  advanced  at  the  time  the  operation  is  per- 
formed. The  operative  treatment  may  be  considered  in 
the  following  stages  : — 

1.  Before  primary  rupture  or  abortion. 

2.  At  the  time  of  primary  rupture. 

3.  Subsequent  to  rupture. 

4.  When  the  embryo  and  placenta  have  occupied  the 
broad  ligament. 

This  fourth  stage  will  require  to  be  considered  in 
sections,  thus  : — 

(a)  At  or  near  term ;  the  child  being  alive. 
(^)  At,   near,  or  after  term ;   the   child    being  dea^/, 
•imivunified^  or  in  the  condition  of  a  lithopcedion. 
{c)  After  decomposition  of  the  foetus  and  suppuration 
in  the  sac. 


At  the  Time  of  Rupture.  417 

1.  Before    primary   rupture    or   abortiou. — 

Opportunities  of  removing  a  gravid  tube  before  rupture 
are  extremely  rare,  and  in  most  of  the  cases  in  which  it 
has  been  carried  out  the  nature  of  the  tubal  mischief 
has  not  been  appreciated.  Such  cases  have  been  usually 
classed  as  hcEmatosalpinx. 

Herman's  case,  in  which  he  diagnosed  tubal  preg- 
nancy and  operated  before  rupture  had  taken  place,  is  as 
yet  without  parallel. 

2.  At  the  tiuie  of  primary  rupture  or  abor- 
tiou.— The  major  ty  of  cases  of  tubal  pregnancy  come 
under  observation  at  the  time  of  primary  rupture  or 
abortion,  and  this  is  usually  some  period  between  the 
fourth  and  twelfth  week. 

When  the  symptoms  of  haemorrhage  are  unmis- 
takable and  the  patient's  life  in  grave  danger,  abdominal 
section  should  be  performed  without  delay,  unless  there 
is  good  evidence  that  the  rupture  is  extra-peritoneal. 
The  employment  of  this  method  is  in  strict  accordance 
with  the  canon  of  surgery  valid  in  other  regions  of  the  body : 
viz.  arrest  hsemorrhage  at  the  earliest  possible  moment. 

There  are  few  accidents  that  test  the  skill,  nerve, 
and  resources  of  a  surgeon  more  than  an  abdominal 
section  for  a  suspected  intra-peritoneal  rupture  of  a 
gravid  tube,  and  few  operations  are  followed  by  such 
brilliant  results. 

The  method  of  performing  the  operation  before 
and  at  the  time  of  primary  rupture  is  identical  with 
oophorectomy. 

Occasionally  the  rent  in  the  tube  will  involve  the 
fundus  of  the  uterus,  especially  when  the  ovum  is  lodged 
near  the  uterus.  Such  rents  should  be  carefully  sutured 
with  gut. 

3.  Subsequent  to  priuiary  rupture.  —  The 
majority  of  cases  are  submitted  to  operation  at  periods 

B   B 


41 8  Tubal  Pregnancy. 

varying  from  a  few  days  to  weeks,  or  even  months,  after 
the  tube  has  ruptured.  It  has  been  aheady  pointed  out 
that  in  an  exceedingly  large  proportion  of  cases  the 
ovum  in  the  tube  becomes  "  apoplectic,"  and  this  con- 
dition is  associated  with  death  of  the  embryo. 

When  the  tube  ruptures  the  haemorrhage  may  not  be 
so  profuse  as  to  induce  death,  and  the  patient,  recovering 
from  the  shock,  does  not  manifest  such  grave  symptoms 
as  to  induce  the  medical  attendant  to  resort  to  surgical 
aid.  The  consequence  is  that  the  patient  remains  for 
several  weeks  under  palliative  treatment  (unless  a  renewal 
of  bleeding  kills  her),  and  at  last  surgical  advice  is 
sought,  the  true  nature  of  the  case  appreciated,  and 
abdominal  section  is  performed. 

In  such  cases,  when  the  abdomen  is  opened  the  free 
blood  in  the  peritoneal  cavity  is  washed  out  by  a  stream 
of  warm  water,  as  directed  in  chapter  xl.  The  damaged 
tube  and  ovary  are  removed  as  in  oophorectomy.  When 
much  free  blood  exists  in  the  peritoneal  cavity,  care  must 
be  taken  that  no  clots  are  allowed  to  remain  in  the  iliac 
fossae.  When  blood  has  remained  in  the  peritoneal 
cavity  for  several  weeks  after  rupture,  it  is  invariably 
necessary  to  drain. 

4.  Broad  ligament  g^estatioii. — -When  therupture 
takes  place  so  that  the  blood  is  extravasated  between 
the  layers  of  the  broad  ligament  and  the  ovum  is 
"  apoplectic,"  operative  interference  is  rarely  called  for. 
In  a  small  proportion  of  cases  the  embryo  survives  the 
displacement,  and  continues  to  grow. 

At  any  date  from  this  period  up  to  term,  surgical 
interference  may  be  called  for  to  save  the  patient  from 
the  disastrous  effects  of  secondary  rupture  into  the 
peritoneal  cavity. 

When  gestation  has  not  advanced  beyond  the  fourth 
month,  it  is  possible  to  remove  the  embryo,  tube,  ovary, 


Treatment  of  the  Sac.  .     419 

and  adjacent  portion  of  the  broad  ligament  with  the 
placenta,  and  to  thoroughly  remove  all  blood-clot. 
Then,  by  transfixing  the  broad  ligament  and  tying  the 
parts  with  silk  ligatures,  the  cavity  may  be  completely 
obliterated,  and  the  ovary,  with  that  portion  of  the  tube 
on  the  distal  side  of  the  ligature,  cut  away. 

When  gestation  has  advanced  beyond  the  fourth 
month  the  placenta  has  become  too  large  to  be  dealt 
with  in  this  summary  manner  ;  at  the  same  time,  the  sac 
has  encroached  upon  the  peritoneum  belonging  to 
adjacent  organs,  such  as  uterus  and  rectum_,  bladder,  and 
not  infrequently  the  anterior  wall  of  the  abdomen. 

After  the  fifth  month  operative  measures  for  tubal 
gestation  must  be  considered  under  two  headings  : — 
(i)  The  treatment  of  the  sac ;  (2)  The  treatment  of  the 
placenta. 

Tlie  treatnieiit  of  the  sac. — The  gestation  sac  in 
the  last  stages  of  tubal  pregnancy  consists  of  the  remnants 
of  the  expanded  tube  and  the  broad  ligaments,  which 
may  be  thickened  in  some  parts  and  expanded  in  others. 
To  the  walls  of  the  sac  coils  of  intestine  and  omentum 
usually  adhere. 

The  removal  of  such  a  sac  is  fraught  with  consider- 
able risk  not  only  to  the  adjacent  large  blood-vessels,  but 
to  the  viscera  and  ureters.  Nevertheless,  in  spite  of 
the  great  risk  of  such  a  proceeding,  it  has  on  one 
occasion  been  successfully  accomplished,  and  the  patient 
luckily  recovered.*  It  wall  generally  be  found  that  in 
cases  where  attempts  have  been  made  to  dissect  out  the 
sac,  the  operation  was  begun  under  the  impression  that 
the  abnormal  mass  w^as  a  tumour,  f  The  only  instance 
in  which  I  have  seen  an  attempt  made  in  this  direction. 


*  Thornton:   Trans.  Obstet.  Soc,  vol.  xxiv.  p.  8i. 
t  Doran  :  Ibid.,  vol.  xxix.  p.  491. 

B  B    2 


420  Tubal  Pregnancy. 

an  obstetric  physician  thought  that  he  had  to  deal  with  a 
sloughing  uterine  myoma.  He  succeeded  in  removing 
the  mass,  and  on  examining  it  after  the  operation,  found 
it  to  be  a  gestation  sac.  The  patient  died  immediately 
after  the  operation. 

Experience  has  decided  clearly  enough  that  the  safest 
plan  is  to  incise  the  sac,  remove  the  foetus,  and  stitch 
the  edges  of  the  sac  to  the  abdominal  wound,  precisely 
as  in  the  plan  recommended  after  enucleating  large  cysts 
and  tumours  from  between  the  layers  of  the  broad 
ligament. 

In  those  cases  where  the  gestation  has  well  advanced, 
the  peritoneum  may  be  so  removed  from  the  anterior 
abdominal  wall  that  the  sac  can  be  penetrated  without 
intentionally  opening  the  peritoneal  cavity  at  any  stage 
of  the  operation. 

The  step  which  perplexes  the  operator  is  how  to  deal 
with  the  placenta.  There  can  be  no  doubt  that  the 
situation  of  the  placenta  largely  influences  the  result,  and 
as  far  as  I  can  judge  from  the  reports  of  cases,  as  well 
as  from  many  operations  I  have  witnessed,  the  most 
promising  cases  are  those  in  which  the  placenta  is 
situated  in  the  pelvis,  below  the  foetus. 

When  the  placenta  is  situated  above  the  foetus  it 
will,  in  many  cases,  be  incised  as  the  sac  is  opened,  and 
give  rise  to  such  furious  bleeding  that  in  several  cases 
the  patient  has  succumbed  to  the  haemorrhage.  Even 
prompt  seizure  and  ligature  of  the  broad  ligament  on  the 
uterine  side  of  the  sac  fail  to  arrest  the  bleeding ;  in 
such  a  case  the  abdominal  aorta  must  be  compressed. 

Various  methods,  such  as  packing  with  sponges  and 
the  application  of  perchloride  or  persulphate  of  iron  to 
the  bleeding  surfaces,  have  been  adopted,  and  in  a  few 
instances  with  success. 

The  fear  of  such  hsemorrhage  and  its  uncontrollable 


Treatment  of  the  Placenta.  421 

character  have  induced  several  surgeons  to  adopt  the 
alternate  plan  of  leaving  the  placenta,  and  allowing  it  to 
gradually  slough  away,  taking  care,  of  course,  to  keep  up 
a  free  communication  with  the  exterior.  The  dis- 
advantages of  this  method  are  many.  The  process  of 
suppuration  and  discharge  of  the  placenta  is  long  and 
dangerous,  on  account  of  the  great  risk  the  patient  runs 
of  septicasmia  and  peritonitis ;  in  a  large  proportion  of 
cases  a  f^cal  fistula  forms ;  in  the  majority  of  cases, 
however,  such  fistulse  gradually  close  as  the  patient 
convalesces. 

In  order  to  avoid  this  risk,  attempts  have  been  made, 
after  removing  the  foetus,  to  thoroughly  irrigate  the 
gestation  sac,  tie  the  cord  close  to  the  placenta  without 
disturbing  the  latter,  cautiously  sponging  the  cavity  and 
then  hermetically  closing  it,  in  the  hope  that  the 
placenta  will  atrophy. 

Unfortunately  for  this  method,  there  is  another  source 
of  infection  to  reckon  with.  It  has  already  been  men- 
tioned that  as  the  gestation  sac  enlarges  it  frequently 
strips  the  peritoneum  from  the  rectum,  and  the  placenta 
itself  may  acquire  adhesions  to  the  bowels.  The  result 
is  that  intestinal  gases  gain  access  to  the  placenta,  and 
set  up  decomposition. 

With  our  present  experience,  the  rules  for  the  treat- 
ment of  the  placenta  may  be  formulated  thus  : — 

1.  When  the  placenta  is  situated  above  the  foetus  it 

is  good  practice  to  attempt  its  removal  with  the 
foetus. 

2.  In  some  instances  the  placenta  becomes  detached  in 

the  course  of  the  operation,  and  leaves  no  choice. 

3.  When  the  placenta  is  below  the  foetus,  it  may  be  left. 

4.  Should  the  placenta  be  left,  the  sac  closed,  and 

symptoms  of  suppuration  occur,  then  the  wound 
must  be  re-opened  and  the  placenta  removed. 


42  2  Tubal  Pregnancy, 

5.  If  the  foetus  dies  before  the  operation  is  attempted, 
the  placenta  can  be  removed  without  risk  of 
haemorrhage. 

Could  we  feel  sure  that  the  placenta  would  not 
decompose,  the  best  method  would  be  to  hermetically 
close  the  sac,  and  wait  until  we  know  that  the  placental 
circulation  had  ceased,  then  re-open  the  sac  and  take 
out  the  placenta.  Unfortunately,  we  have  no  precise 
data  to  guide  us  in  this  respect,  and  whilst  waiting  for  the 
placental  circulation  to  cease,  the  placenta  decomposes. 

The  great  risk  of  violent  haemorrhage  from  the 
placental  site  renders  an  operation  for  tubal  pregnancy 
between  the  fifth  and  ninth  months  of  gestation,  the 
fo2tus  being  alive,  the  most  dangerous  in  the  whole 
range  of  surgery  ;  hence  it  cannot  be  urged  with  too  much 
force  that,  when  it  is  fairly  evident  that  a  woman  has 
a  tubal  or  broad  ligament  pregtiancy^  it  should  be  dealt 
iviih  by  operation  without  delay. 

Dr.  Braithwaite*  has  recorded  a  case  in  which  he 
performed  laparotomy,  and  removed  a  full-grown  extra- 
uterine foetus,  which  had  been  dead  about  three  weeks. 
The  placenta,  adherent  to  the  posterior  surface  of  the 
uterus,  was  not  interfered  with.  The  wound  was  closed 
except  at  its  lower  angle,  where  the  funis  was  left 
hanging  out ;  and  a  drainage-tube  inserted.  In  this 
instance  the  patient  slowly  recovered,  and  the  placenta 
did  not  come  away. 

In  the  discussion  which  followed  the  reading  of  the 
history  of  this  case,  Dr.  Champneys  made  the  ingenious 
suggestion  that  in  order  to  prevent  sepsis  of  the  placenta 
an  attempt  might  be  made  to  peel  off  the  amnion  and 
wash  out  the  vessels  of  the  funis  with  boro-glyceride ;  this 
solution  would  be  harmless  if  absorbed. 

Another  objection  that  has  been  urged  against  leaving 

*   Trans.  Obstet.  Soc,  London,  vol.  xxviii.  p.  33. 


Character  of  the  Fcetus.  423 

the  placenta  is  that  it  may  continue  to  grow.  This  need 
not  be  seriously  entertained.  It  is  beyond  doubt  that 
in  cases  of  tubal  gestation  the  placenta  is  large  out  of  all 
proportion  to  the  embryo,  and  in  many  cases  a  small 
shrivelled  foetus,  which  has  been  dead  many  weeks,  is 
found  attached  to  a  placenta  larger  than  an  ordinary 
placenta  of  a  full-time  uterine  gestation.  Even  allowing 
a  large  margin  for  haemorrhages  into  the  placenta,  I  feel 
convinced  that  an  extra-uterine  placenta  in  some  cases 
continues  to  grow  after  the  premature  death  of  the 
foetus.  But  no  one,  so  far  as  I  am  aware,  has  succeeded 
in  proving  that  after  removal  of  the  foetus  the  placenta, 
when  left  behind,  has  continued  to  grow.  Until  this  has 
been  demonstrated  it  is  visionary  to  take  it  into  account 
when  seriously  considering  how  to  deal  with  the  placenta. 
It  has  been  urged  that  if,  dSttx  prifnary  rupture,  there 
is  evidence  that  the  child  is  developing  in  the  broad 
ligament,  operative  interference  should  be  deferred  until 
the  seventh  month,  unless  urgent  symptoms  arise,  as 
there  may  be  a  prospect  of  saving  the  child's  life.  To 
my  mind,  this  is  an  objectionable  practice,  for  the 
following  reasons  : — 

1.  Extra-uterine  children  are  puny,   ill-developed, 

and  in  a  large  proportion  of  cases  malformed, 

2.  They  rarely  survive  the   delivery  many  weeks, 

at  most  months.  Of  the  six  cases  arranged  on 
the  subjoined  table,  five  were  dead  before  the 
end  of  the  first  year. 

3.  In  endeavouring  to  save   the  life   of  an  unsatis- 

factory child,  the  more  valuable  life  of  the 
mother  is  frequently  sacrificed.  Compare  tables 
on  pages  424  and  425,  which  have  been  compiled 
for  this  purpose. 
It  is,  of  course,  conceivable  that  in  some  cases  the 
life  of  the  child  may  be  of  very  great  importance. 


424 


Tubal  Pregnancy. 


Champneys*  has  dealt  with  this  question  from  a  much 
larger  series  of  cases.  I  have  confined  myself  entirely 
to  the  records  of  British  surgeons,  with  the  hope  that 
some  industrious  authors  in  America,  France,  and 
Germany  will  furnish  similar  returns,  gathered  from  cases 
reported  in  the  periodical  literature  of  these  countries 
during  the  last  ten  or  fifteen  years.  This  would  provide 
a  trustworthy  basis  for  guidance  in  this  important  matter. 

Operations  by  British  Surgeons,  performed  between  7th 
AND  9TI1  Month  of  Gestation — the  Child  being  alive. 


Opsrator. 

Date  of 

Treatment  of 

Result. 

PLACE  OF 

Pregnancy. 

PLACENTA. 

Record. 

Jessop 

33rd  to  34th 

Left.        It    de- 

Mother    recovered. 

Trans.  Ohstet. 

week. 

composed,  and 

Child      died       11 

Society,   vol. 

came  away  be- 

months after  birth. 

■    xviii.  p.  261. 

tween  the  5th 

and  32nd  day. 

Lawson  Tait 

Placenta  left  ... 

Mother  died  4  days 
after        operation. 
Protracted   shock. 
Child       stirvived 
and     has    grown 
into     an     elegant 
•woman,  t 

British  Med. 
Jour.,  1880, 
vol.  !.  p. 
737- 

Gervis 

About    full 

Placenta  _    left. 

Mother       died      56 

British    Med. 

term. 

Sac  drained. 

hours  after  opera- 
tion ;  haemorrhage 
and        peritonitis. 
Child     lived      six 
hours. 

Jon>-.,  vol. 
ii.  p.  884. 

Champneys 

About     7th 

Placenta      left. 

Mother    died    from 

Tfans.  Ohstet. 

month. 

Placenta     de- 

chronic  septic    in- 

Society, vol. 

composed. 

toxication,    due  to 
decomposition     of 
placenta,   80   days 
after        operation. 
Child    died     50on 
after  operation. 

xxix.  p.  456. 

John     Wil- 

34th to  35th 

Left.    It  gradu- 

Mother    recovered. 

Trans.  Obstet. 

liams. 

week. 

ally    sloughed 

Child  lived  only  a 

Soc,  Lond. 

out  piecemeal. 

few  hours. 

vol.   xxix.  p. 

482. 

Taylor 

Left.      Decom- 

Mother   recovered. 

Trans.  Obstet. 

posed, and  was 

Child  lived  eleven 

Soc,  Lond., 

removed       on 

months. 

vol.     xxxiii. 

i2thday.  Pro- 

p. 115. 

fuse    haemorr- 

hage. 

*   Trans.  Obstet.  Soc,  London,  vol.  xxix,  p.  476. 

f  Mr.  Law^son  Tait  kindly  furnished  me  witli  this  fact  in  a  letter. 


After  Death  of  the  Fcetus. 


42.') 


After  death  of  the  fcptus  at  or  near  term. — 

Operations  after  the  death  of  the  fcetus  are  less  complicated 
than  when  the  child  is  alive  and  the  placental  circulation 
in  full  vigour.  Not  only  is  the  proceeding  from  the  opera- 
tive point  of  view  simplified,  but  the  results,  in  so  far  as 
the  mother  is  concerned,  are  much  more  satisfactory. 

For  instance,  in  the  preceding  list  of  operations  per- 
formed in  England  for  extra-uterine  gestation  in  which 
the  fcetus  was  between  the  seventh  and  ninth  month,  and 
alive  at  the  time  of  the  operation,  there  were  six  cases, 
with  three  recoveries.  In  the  subjoined  list  of  seven 
cases,  in  which  the  operation  was  performed  for  the  re- 
moval of  a  dead  foetus  varying  in  ages  from  the  seventh 
to  the  ninth  month,  all  the  mothers  recovered.  Such 
records  tell  their  own  tale. 

Operations  for   Extra-uterixe   Pregnancy  after  Death 
OF  THE  Child  at  or  near  Term. 


Operator. 

LENGTH  OF  Time 

AFTER  Death 

OF  Fcetus. 

Condition  of  Child  |  t?cct-t  t 
AND  Placenta.         ^esllt. 

Place  of 
Record. 

Braithwaite 

14      days      after 

Placenta  was  left,  and  Recovery 

Lancet,      1885, 

(James), 

spuriouslabour 

during     the     subse- 

vol. i.  p.  7. 

at  full  term. 

quent  3  weeks  slow-, 
ly      sloughed       out 
through    the    lower 
angle  of  wound.         j 

Braithwaite 

About  T  month... 

Placenta  left  :    it  was:  Recovery 

Ibid. 

(James). 

removed     6     weeks 
after  operation. 

Braithwaite 

3  weeks  

Placenta  left :  it  never  Recovery 

Trans.    Obstet. 

Games). 

came  away. 

Society,     vol. 

xxviii.  p.  23. 

Herman 

2  months 

Placenta  weighed  28^ 
ounces,        removed 
with    foetus,    which 
weighed  3  lbs.  8  oz. 

Recovery 

Trans.    Obstet. 
Society,     vol. 
xxviii.  p  144. 

Cullingworth. 

8  months 

Placenta  removed  with:  Recovery- 

Trans.    Obstet. 

foetus  ;  no  umbilical! 

Sac. ,  London, 

cord,      no      haemor- 

vol.    x.xx.    p. 

rhage. 

480. 

Worrali        of 

15  months 

Placenta  left :  no  men-  Recovery 

Medical    Press 

Sydney. 

tion    of    its    subse- 

andCircular, 

quent  behaviour.       1 

Mar.  25,  1891. 

Sheild 

Placenta       removed  :  Recovery- 

Trans.     Obstet. 

child     decomposed, 

Society,     vol. 

and  its  buttocks  pre- 

xxxiii. p.  148. 

senting    through    a 

sinus    in    an    abdo- 

minal wall. 

426  Tubal  Pregnancy. 

After  decomposition  of  the  foetus  and  sup- 
puration of  the  sac. — After  death  and  decomposition 
of  the  foetus,  sinuses  form,  by  which  pus  finds  an  exit, 
either  through  the  rectum,  vagina,  bladder,  uterus,  or  at 
some  spot  in  the  anterior  abdominal  wall  below  the  um- 
bilicus, accompanied  by  fragments  of  foetal  tissue  and 
bones.  The  treatment  in  such  cases  is  simplicity  itself. 
The  sinuses  should  be  dilated,  and  all  fragments  removed 
from  the  cavity  in  which  they  lie.  When  this  is  thoroughly 
done,  the  sinuses  will  rapidly  granulate  and  close.  Partial 
operations  are  useless ;  if  only  a  portion  of  a  bone  is 
allowed  to  remain,  a  troublesome  sinus  will  persist. 

Operations  for  the  relief  of  tubal  gestation  through 
the  vagina  are  not  satisfactory,  and  have  not  found 
favour  among  surgeons.  This  method  of  operating  has 
been  fully  discussed  by  Dr.  Herman  in  a  paper  com- 
municated to  the  Obstetrical  Society,  London,  in  1887. 

Dr.  Herman  has  collected  thirty-three  cases  in  which 
an  extra-uterine  gestation  sac  has  been  emptied  through 
the  vagina,  and  from  an  examination  of  them  he  drew 
the  following  conclusions  : — 

1.  The  operation  of  opening  an  extra-uterine  gestation 

sac  by  the  vagina  early  in  pregnancy,  before 
rupture  has  taken  place,  by  the  cautery,  knife, 
or  otherwise,  is  a  dangerous  and  unscientific 
proceeding.  Abdominal  section  ought  at  this 
time  always  to  be  preferred. 

2.  Immediately  after  rupture  has  taken  place,  when 

interference  is  called  for  to  arrest  internal 
haemorrhage,  the  abdominal  operation  is  more 
likely  to  be  successful  than  the  vaginal. 

3.  After  rupture  has  taken  place,  and  the  effusion  pf 

blood  has  been  followed  by  pyrexia,  the  indica- 
tions for  incision  of  the  vagina  are  the  same  as 
in  hsematocele  from  any  other  cause. 


Operations  through  the   Vagina.  427 

4.  At,  or  soon  after,  full  term,  before  suppuration  has 

taken  place,  there  may  be  conditions  which 
indicate  delivery  by  the  vagina  as  preferable  to 
abdominal  section.     These  are  : — 

5.  When  the  fcetus  is  presenting  by  the  head,  feet,  or 

breech,  so  that  it  can  be  extracted  without 
altering  its  position  ;  and 

6.  When  it  is  quite  certain,  from  the  thinness  of  the 

structures  separating  the  presenting  part  from 
the  vaginal  canal,  that  the  placenta  is  not  im- 
-  planted  on  this  part  of  the  sac,  and  it  is  not 
equally  certain  that  the  placenta  is  not  attached 
to  the  anterior  abdominal  wall. 

7.  If  the  child  cannot  be  delivered  by  the  vagina 

without  being  turned,  abdominal  section  should 
be  performed. 

8.  No  attempt  should,  as  a  rule,  be  made  to  remove 

the  placenta. 

9.  The    after-treatment   should   consist   in   frequent 

washing  out  of  the  sac. 
10.  After  suppuration  has  taken  place,  the  opening  of 
the  sac  into  the  vagina  is   one  of  the  more 
.   favourable  terminations. 
A  careful  perusal  of  Dr.  Herman's  paper  will  serve 
to  convince  anyone  who  will  take  the  trouble  to  compare 
the  results  with  those  obtained  by  the  abdominal  method, 
that  delivery  by  the  vagina  is  only  suitable  for  cases  in 
which  the  fcetus  has   decomposed,  and  the  macerated 
remnants  of  its  body  are  being  discharged  through  a 
fistulous  tract  opening  into  this  canal. 


fart    XY. 

METHODS    OF   PERFORMING 

OPERATIONS    FOR    OVARIAN     AND 

TUBAL  DISEASES. 


CHAPTER     XXXVIII. 

OVARIOTOMY. 

Ovariotomy  signifies  the  removal  through  an  abdominal 
incision  of  cystic  and  solid  tumours  of  the  ovary,  cysts  of 
the  parovarium,  and  ovarian  hydroceles. 

I.  Preparation  of  the  patient. — It  is  a  great 
advantage,  when  it  can  be  carried  out,  to  keep  the 
patient  confined  to  bed  two  or  three  days  immediately 
before  the  day  of  operation.  She  should  be  prepared 
as  for  any  other  serious  surgical  proceeding  :  the  rectum 
should  be  emptied  by  means  of  enemata,  and  the  patient 
should  be  strictly  enjoined  to  take  no  food  for  several 
hours  before  the  operation;  this  diminishes  the  chances 
of  vomiting. 

It  is  a  great  advantage  to  operate  in  the  early 
morning,  the  patient  should  take  a  light  meal  about 
eight  o'clock  the  preceding  evening,  and  then  abstain 
from  food  or  drink  until  after  the  operation.  In  young 
patients  this  causes  no  inconvenience,  but  in  elderly 
women  it  is  necessary  to  modify  it  by  allowing  some  milk 
or  a  cup  of  tea  in  the  early  morning. 

Before  the  surgeon's  arrival  the  nurse  prepares  the 
patient.  She  should  simply  wear  a  clean  linen  night- 
dress, warm  stockings,  and  a  pair  of  plain  flannel  drawers. 


Ovariotomy.  429 

Just  before  entering  the  room  the  bladder  should  he 
emptied  naturally  or  by  means  of  a  catheter.  In  the 
meantime,  the  surgeon  and  his  assistant  prepare  the 
instruments. 

In  addition  to  the  ordinary  instruments,  such  as 
knives,  forceps,  needles,  sutures,  etc.,  required  in  surgical 
operations  generally,  the  following  will  be  needed : — A 
pedicle-needle  and  silk  of  various  thicknesses  for  tying  the 
pedicle,  an  ovariotomy  trocar  for  tapping  the  cyst,  strong 
and  trustworthy  forceps  for  seizing  the  cyst  wall  or 
pedicle,  a  clamp,  or  a  serre-noeud,  transfixing  pins,  and 
glass  drainage-tubes  of  various  sizes. 

Spotiges  a7id  forceps  should  always  be  coiuited  before  the 
operation^  and  the  number  written  doivJi. 

The  water  in  which  the  sponges  are  immersed  must 
be  about  the  ordinary  temperature  of  the  body.  The 
fluid  used  for  the  immersion  of  instruments  varies  with 
the  fancy  of  the  operator.  Equally  good  results  in 
practised  hands  follow  the  employment  of  tepid  water  or 
solutions  of  carbolic  or  boracic  acid.  It  will  be  wise  for 
beginners  to  employ  strict  antiseptic  precautions,  and 
then  modify  them  as  they  acquire  experience. 

The  spray  is  a  useless  and  not  altogether  harmless 
encumbrance. 

The  niirse. — Success  in  ovariotomy  depends  in  no 
smaU  measure  on  the  nursing.  It  is  therefore  desirable 
to  employ  a  nurse  who  has  had  special  training  in 
"  ovarian  nursing."  The  most  trustworthy  nurses  are  those 
who  love  their  work  and  willingly  carry  out  implicitly  the 
instructions  of  the  surgeon.  They  must  be  able  to  pass 
a  catheter  or  administer  an  enema  without  causing  the 
patient  pain  ;  to  understand  the  administration  of  liquid 
food  in  regular  quantities  and  at  fixed  intervals;  and 
above  all  things,  they  must  not  be  chatterers. 

The  room. — The  selection  of  a  room  for  ovariotomy 


43 o  Ovarian  and   Tubal  Diseases. 

is  made  on  the  same  principles  as  for  other  major  opera- 
tions of  surgery.  In  hospital  practice  it  is  the  fashion  to 
perform  ovariotomy  in  a  special  room.  This  is  quite  un- 
necessary ;  I  operate  in  the  theatre,  and  treat  the  patient 
in  a  general  ward  with  the  most  satisfactory  results. 

The  table. — ^In  arranging  the  table,  it  is  necessary 
to  place  beneath  the  sheet  or  blanket  on  which  the  patient 
lies  a  broad  piece  of  waterproof  material.  Many  surgeons 
cover  the  patient's  abdomen  with  a  sheet  of  waterproof 
with  a  large  hole  cut  in  the  centre.  This  serves  to  protect 
the  patient's  clothes,  but  it  is  cumbersome. 

Aii£e!$tlieis»Ja. — Some  surgeons  advocate  ether,  others 
chloroform ;  each  has  its  advantages  and  disadvantages. 
On  the  whole,  I  prefer  chloroform,  the  patient  being  first 
rendered  unconscious  by  nitrous  oxide.  This  saves  time 
and  often  strugghng. 

The  ahdomiiial  ineisioii. — The  patient  being 
completely  under  the  influence  of  the  anaesthetic,  the  pubes 
should  be  shaved,  unless  the  nurse  has  done  this  pre- 
viously. The  surgeon,  standing  on  the  right-hand  side  of 
the  table,  the  assistant  being  opposite  him,  divides  the 
integuments  in  the  middle  of  the  abdomen,  beginning 
a  little  below  the  umbilicus,  and  extending  it  down- 
wards to  the  symphysis.  As  a  rule,  the  first  incision  is 
about  7  cm.  in  length,  and  should  extend  through 
the  skin  and  subcutaneous  fat  to  the  linea  alba.  Any 
bleeding  vessels  are  immediately  secured  with  forceps. 
The  linea  alba  is  then  incised,  and  usually  the  sheath  of 
the  rectus  of  one  or  other  side  is  opened.  With  a  little 
care,  it  is  easy  to  find  the  median  strip  of  fibrous  tissue ; 
and  care  should  be  exercised  in  this,  for  if  the  surgeon 
fumbles  about  among  the  fibres  of  the  rectus,  he  will  be 
troubled  with  the  small  arteries  belonging  to  that  muscle. 
After  dividing  the  sheath  of  the  rectus,  the  sub-peritoneal 
tissue  is  exposed.     This  varies  considerably  in  amount : 


OVARIO  TOMV.  43  I 

in  spare  subjects  it  is  little  more  than  a  delicate  layer  of 
connective  tissue;  in  fat  subjects  it  may  be  very  thick 
and  granular,  and  resemble  omentum. 

At  this  stage  the  urachus  may  sometimes  be  recog- 
nised, and  occasionally  the  bladder  is  spread  out  over 
the  floor  of  the  incision.  An  experienced  operator 
quickly  recognises  the  tissue  of  the  bladder,  but  it  may 
puzzle  an  inexperienced  surgeon,  and  it  has  been  opened 
by  the  scalpel,  especially  when,  as  is  sometimes  the  case, 
it  is  pushed  upwards  by  a  pelvic  tumour.  The  peri- 
toneum is  now  exposed,  and  in  order  to  open  this  without 
injuring  the  cyst  or  the  intestine,  a  fold  of  it  is  picked  up 
with  dissecting  forceps  and  cautiously  pricked  with  the 
point  of  the  scalpel. 

Dividing  the  peritoneum  is  an  important  step  in  the 
operation.  It  may  adhere  to  the  tumour,  and  be  cut 
through  before  the  surgeon  is  aware  of  it,  in  which  case 
he  may  cut  through  the  cyst  wall,  mistaking  it  for  peri- 
toneum, an'd  will  be  suddenly  apprised  of  his  error  by 
the  fluid  gushing  forth.  When  there  is  free  fluid  in  the 
peritoneal  cavity,  it  will  flow  out  when  the  peritoneum  is 
divided,  and  the  operator  may  for  a  moment  think  he 
has  opened  the  cyst.  A  more  serious  error  is  to  mistake 
peritoneum  for  cyst  wall,  and  set  about  detaching  it  from 
the  parietes.  As  soon  as  the  peritoneum  has  been 
opened,  the  edges  should  be  held  by  pressure-forceps, 
whilst  it  is  divided  to  an  extent  nearly  equal  to  the  skin 
wound.  This  may  be  done  with  a  scalpel  and  director,  or 
scissors,  or  a  probe-pointed  bistoury,  using  two  fingers  as 
a  guide.  Should  the  cyst  be  pricked  so  as  to  allow  of  the 
fluid  escaping,  the  cut  edges  should  be  immediately 
seized  with  forceps  and  drawn  out  through  the  wound. 

The  peritoneal  cavity  being  opened,  the  operator 
anxiously  looks  for  the  glistening  surface  of  the  ovarian 
cyst,  and  then  inserts  the  fingers,  and  sweeps  them  over 


432  Ovarian  and  Tubal  Diseases. 

the  wall  of  the  tumour  to  ascertain  the  existence  or 
absence  of  adhesions. 

Instead  of  the  typical  ovarian  cyst,  he  may  find  a 
condition  of  things  which  requires  investigation  before 
proceeding  further.  The  tumour  may  be  solid  or  uterine 
in  origin  ;  the  escape  of  bloody  fluid  and  small  secondary 
knots  on  the  parietal  peritoneum,  omentum,  and  intes- 
tines may  suggest  malignancy.  The  adhesions  may  be 
so  numerous  that  he  hesitates  to  continue  the  operation. 

It  is  of  the  highest  importance  to  be  satisfied  as  to 
the  nature  of  the  tumour  ;  to  plunge  a  trocar  into  a  preg- 
nant uterus  or  a  uterine  tumour  is  an  accident  v*^hich 
involves  the  operator  in  anxious  difficulty. 

Decomposing  fluid,  tenacious  mucus  from  a  ruptured 
cyst,  or  blood  may  obscure  the  parts.  Such  may  be 
washed  away  by  irrigating  the  cavity  with  water  at  iio°. 
This  is  far  more  satisfactory  and  much  quicker  than 
sponging,  and  has  the  advantage  of  not  fouling  the 
sponges. 

Much  free  blood  in  the  peritoneal  cavity  suggests 
rupture  of  a  gravid  tube,  tubal  abortion,  or  secondary 
rupture  of  a  gestation  sac.  More  rarely  it  is  due  to  rup- 
ture of  an  ovarian  cyst,  secondary  to  twisting  of  the 
pedicle. 

Emptying:  tlie  cyst. — Feeling  satisfied  that  the  tu- 
mour contains  fluid,  and  is  unconnected  with  the  uterus, 
the  operator  proceeds  to  tap  it.  The  trocar  is  thrust  into 
the  cyst,  and  the  fluid  rushes  through  it  to  the  receptacle 
beneath  the  table.  As  the  cyst  collapses  the  sharp  edge 
of  the  trocar  is  rendered  harmless  by  drawing  it  into  the 
cannula  ;  the  cyst  wall  is  seized  with  forceps,  and  drawn 
into  the  grasp  of  the  spring  hooks  on  the  side  of  the 
trocar,  and  secured.  As  the  cyst  collapses,  it  is  gently 
withdrawn  through  the  incision,  whilst  the  assistant  keeps 
the  abdominal  wail  closely  applied  to  the  cyst,  and  follows 


Ovariotomy.  433 

its  contraction  by  gentle  pressure  ;  as  the  last  part  of  the 
cyst  passes  through  the  incision  he  prevents  the  intes- 
tines from  escaping  by  the  prompt  application  of  a 
sponge. 

Tapping  a  cyst  is  not  always  so  simple.  The  cyst 
may  contract  up  to  a  point,  and  the  fluid  cease  to  flow ; 
this  may  be  due  to  a  large  secondary  cyst.  The  trocar 
may  then  be  protruded  from  the  cannula,  and  used  to 
tap  it.  In  some  cases  the  fluid,  when  thick  and  viscid, 
flows  with  difticulty,  or  the  tumour  may  be  multilocular ; 
under  such  conditions,  the  operator  removes  the  trocar, 
enlarging  the  opening  in  the  cyst,  inserts  the  hand,  and 
then  proceeds  to  break  down  the  interior  of  the  tumour, 
until  its  bulk  is  sufliciently  reduced  to  allow  of  its  escape 
through  the  abdominal  wound,  unless  retained  by  adhe- 
sions. 

Adliesioiis. — Although  the  surgeon  may  have  had 
reason  to  suspect  the  presence  of  adhesions,  frequently 
he  finds  none,  and  at  other  times,  when  he  least 
suspects  them,  many  exist.  The  most  frequent  adhe- 
sions are  omental ;  they  are  usually  seized  with  forceps, 
ligatured  with  gut  and  then  divided. 

Large  portions  oi  great  oinentum  may  require  ligature  ; 
instead  of  being  tied  in  a  bunch,  it  should  be  transfixed 
with  an  aneurysm  needle,  armed  with  a  piece  of  gut 
doubled,  and  the  omentum  tied  in  two,  three,  or  four 
places,  according  to  its  width  and  thickness.  Adherent 
appendices  epipldicce  are  easily  dealt  with,  but  intestinal 
adhesio?is  require  care  and  patience.  They  are  rarely 
tough,  and  may  generally  be  detached,  and  if  any  vessel 
bleed  it  should  be  carefully  secured. 

The  vermiform  appendix,  if  firmly  fixed  to  the  tumour, 
may  be  encircled  with  gut,  tied  firmly,  and  cut  through ; 
this  is  a  safer  plan  than  tearing,  or  otherwise  damaging  it 
in  the  process  of  detachment. 
.  c  c 


434  Ovarian  and  Tubal  Diseases. 

Should  the  intestines  be  torn  the  wound  must  be 
sewn  up  by  a  continuous  suture  of  fine  silk. 

Adhesions  to  parietal  perito?iejim.  are  best  detached 
with  the  finger,  and  a  sponge  applied  to  check  oozing. 

When  adhesions  are  extensive  it  may  be  necessary  to 
enlarge  the  wound,  especially  when  the  cyst  is  adherent 
to  the  pelvic  peritoneum,  as  the  iliac  veins,  vena  cava,  or 
ureters  are  liable  to  be  torn. 

Tlie  pedicle. — When  the  tumour  is  drawn  out  of  the 
abdomen  the  pedicle  is  in  most  cases  readily  recognised, 
the  Fallopian  tube  being  an  excellent  guide  to  it.  The 
tissues  constituting  the  pedicle  of  an  ovarian  tumour  are 
the  Fallopian  tube  and  adjacent  parts  of  the  broad  liga- 
ment, containing  the  ovarian  artery,  pampiniform  plexus 
of  veins,  lymphatics,  nerves,  and  ovarian  ligament. 
When  the  tissues  are  not  matted  together  the  round 
ligament  is  readily  seen,  and  should  not  be  included  in 
the  ligature. 

In  tying  a  healthy  pedicle,  the  aim  should  be  to 
transfix  the  broad  ligament  at  a  spot  where  there  are  no 
large  veins,  and  tie  the  structures  in  two  bundles.  The 
inner  half  contains  the  Fallopian  tube,  a  fold  of  the  broad 
ligament,  and  occasionally  the  ovarian  ligament ;  the 
outer  usually  consists  of  the  ovarian  ligament,  veins, 
ovarian  artery,  lymphatics,  and  a  larger  fold  of  the  broad 
ligament  than  the  inner  half. 

Pedicles  differ  greatly ;  they  may  be  long  and  thin, 
or  short  and  broad.  In  some  instances  they  are  wanting, 
and  in  the  case  of  double  fused  cysts  two  pedicles  exist. 

Before  tying  the  pedicle  the  surgeon  examines  its 
relation  to  the  uterus,  ascertains  its  freedom  from  ad- 
hesions, and  the  existence  or  otherwise  of  twists. 

Long  and  thin  pedicles  are  easily  managed ;  the 
assistant  supports  the  tumour  firmly,  but  without  drag- 
ging, or  the   tissues  may  be  torn.     The   surgeon,   with 


Tying  the  Pedicle.  435 

the  thumb  and  index  of  the  left  hand,  spreads  out 
the  tissues,  and  then  transfixes  them  with  the  pedicle 
needle  armed  with  silk.  The  loop  of  silk  is  seized 
as  soon  as  it  appears  on  the  opposite  side,  and  the 
needle  withdrawn. 

Care  must  be  taken  during  the  transfixion  not  to 
prick  any  adjacent  coil  of  bowel,  and  not  thrust  the 
needle  through  the  pedicle  to  an  unnecessary  extent. 
The  threads  must  now  be  tied ;  for  this  purpose  the  loop 
of  silk  is  cut  with  scissors,  so  that  two  ligatures  lie  in  the 
pedicle. 

The  proper  ends  of  each  piece  of  silk  are  secured, 
and  the  thread  intended  for  the  outer  half  of  the  pedicle 
is  made  to  cross  that  intended  for  the  inner  half.  The 
threads  are  then  tied  firmly;  the  outer  half  should  be. 
secured  first.  The  particular  knot  employed  is  of  little 
consequence,  so  long  as  it  is  one  that  will  hold  firmly. 
In  tying  the  threads  some  little  care  is  necessary;  it 
should  be  done  with  steadiness  and  firmness  ;  any  jerking 
is  apt  to  break  the  silk  and  cause  trouble,  besides  the 
risk  of  lacerating  the  tissue  of  the  pedicles ;  whereas,  if 
the  parts  are  not  tightly  embraced  by  the  silk,  they  will 
slip  out  of  the  ligature  and  begin  to  bleed.  When  this 
happens,  after  the  w^ound  has  been  closed  and  the 
patient  returned  to  bed,  it  leads  not  infrequently  to  fatal 
consequences.  In  order  to  avoid  this,  there  are  certain 
points  which  need  attention. 

When  the  pedicle  is  thin  the  method  just  described 
is  quite  a  safe  way  of  applying  the  ligature,  but  with  this 
precaution  :  as  the  surgeon  ties  the  knot  the  assistant 
must  gently  relax  the  parts  by  supporting  the  tumour 
without  allowing  it  to  drag  on  the  pedicle. 

The  knots  employed  to  secure  the  threads  are  various  : 
a  properly  applied  reef  knot  answers  all  practical  pur- 
poses,  and  is   as  simple  as  it  is  efficient.     It  may  be 
c  c  2 


436  Ovarian  and  Tubal  Diseases. 

necessary  in  some  cases  for  greater  safety  to  bring  the 
two  ends  of  the  inner  thread  around  the  entire  pedicle, 
and  tie  them  again,  taking  care  that  the  threads  He  in  the 
groove  formed  by  the  Hgatures  already  applied.  In 
practising  this  manoeuvre,  it  is  advisable  to  fasten  the 
inner  thread  with  three  knots  instead  of  two,  for  if  the 
ends  should  be  crossed  over  the  knot  it  may  be  loosened 
instead  of  tightened.  The  plan  of  tying  the  pedicles  in 
two  pieces,  and  then  encircling  it  with  a  separate  thread, 
is  not  to  be  recommended. 

After  the  operator  has  gained  some  experience  in 
this  simple  mode  of  tying  the  pedicle,  he  may  then,  if  he 
thinks  it  desirable,  practise  other  methods. 

After  securely  applying  the  ligature,  the  tumour  is 
removed  by  snipping  through  the  tissues  on  the  distal 
side  of  the  ligature  with  scissors.  Care  must  be  taken 
not  to  cut  too  near  the  silk,  or  the  stump  will  slip  through 
the  ligature ;  on  the  other  hand,  too  much  tissue 
must  not  be  left  behind.  The  stump  is  seized  on  each 
side  by  pressure  forceps,  and  examined  to  see  that  the 
vessels  in  it  are  secure ;  it  is  then  allowed  to  retreat  into 
the  abdomen.  Should  it  commence  to  bleed,  it  must 
be  re-transfixed  and  tied  below  the  original  ligature. 

Occasionally  a  broad  short  pedicle  will  contain  so 
much  tissue  that  it  will  be  necessary  to  tie  it  with  three 
threads.  To  do  this,  the  pedicle  is  transfixed  with  the  silk, 
the  loop  is  divided,  and  the  two  threads  are  interlocked. 
The  outer  thread  is  tied  as  usual.  The  needle  is  re-filled 
with  a  single  ligature,  and  transfixion  performed.  The 
needle  is  then  unthreaded,  and  the  untied  end  of  the  silk 
belonging  to  the  first  ligature  is  passed  into  the  eye  of 
the  needle,  which  is  then  withdrawn.  The  second  liga- 
ture, before  it  is  tied,  must  be  interlocked  with  the  third 
thread.  When  the  threads  are  tied  they  will  hold  the 
tissues  firmly, 


Sess/le  Cvsrs.  437 

It  is  impossible  to  frame  absolute  rules  for  ligaturing 
the  pedicle.  In  this,  as  in  all  departments  of  surgery, 
common  sense  must  be  exercised,  and  at  the  present  day, 
when  ovariotomy  is  practised  so  widely,  no  one  would 
think  of  performing  this  operation  without  assisting, 
or  watching  its  actual  performance  by,  an  experienced 
surgeon. 

In  a  few  rare  cases  the  pedicle  may  be  so  tightly 
twisted  or  so  attenuated  by  the  dragging  of  the  tumour 
that  it  will  only  require  encircling  with  a  simple  ligature 
without  transfixion. 

In  those  rare  cases  in  which  the  tumour  has  been 
gradually  detached  from  its  uterine  connections  it  has 
no  proper  pedicle.  Unless  the  operator  is  aware  of  this 
he  may  be  exceedingly  puzzled.  Sometimes  the  tissues 
of  the  pedicles  are  inflamed  ;  they  are  then  so  soft  that 
they  easily  lacerate  when  the  ligatures  are  drawn  tight. 
In  double-fused  ovarian  cysts  two  pedicles  require  liga- 
tures. 

Sessile  cysts  lying  deeply  bet\veen  the  layers  of  the 
broad  ligament  cannot  be  treated  in  this  way.  The 
surgeon  taps  the  cyst,  and  finds  that  as  the  fluid  escapes 
he  cannot  draw  the  tumour  through  the  wound ;  he  then 
proceeds  to  enucleate  it  in  the  following  manner.  It  is 
usually  necessary  to  enlarge  the  abdominal  wound ;  the 
capsule  of  the  cyst,  formed  by  the  thickened  broad 
ligament,  is  torn  with  dissecting  forceps,  or  scraped 
through  with  a  knife  until  the  cyst  w^all  is  exposed,  then 
with  the  fingers  the  connective  tissue  between  the  cyst 
and  its  capsule  is  detached,  taking  every  care  not  to 
lacerate  the  capsule  ;  any  bleeding  vessel  is  immediately 
seized  with  forceps.  In  this  w^ay  the  cyst  is  completely 
shelled  out  of  its  bed.  In  some  cases  the  cyst  wall  is 
so  firmly  held  in  the  floor  of  the  pelvis  that  it  involves 
too  much  risk  to  remove  it.     Sometimes  the  base  of  the 


43 S  Ol^ARIAN  AND    TUBAL    DISEASES. 

cyst  when  held  in  this  way  may  be  transfixed  and  tied. 
As  soon  as  the  cyst  is  removed  all  bleeding  must  be 
immediately  checked.  The  treatment  of  the  capsule 
varies.  Sometimes  it  is  possible  after  enucleation  of 
moderate-sized  tumours  to  gather  the  loose  capsule  into 
a  fold,  transfix,  and  ligature  it  like  an  ordinary  pedicle. 
When  the  tumour  is  large  and  has  burrowed  deeply  this 
should  not  be  done,  as  oozing  takes  place  in  the  recesses 
of  the  cavity,  and  will  sometimes  form  a  large  haematoma. 
To  prevent  this  the  edges  of  the  capsule  are  stitched  to 
the  low^er  extremity  of  the  abdominal  wound  and  drained. 
It  occasionally  happens  that  an  attempt  is  made  to 
enucleate  a  cyst,  but  its  deeper  parts  are  so  firmly 
attached  as  to  cause  the  surgeon  to  desist.  In  such 
cases  the  edges  of  the  cyst  and  capsule  are  stitched  to 
the  abdominal  wound  and  the  cavity  is  drained. 

Caiiteriisiiig'  the  pedicle. — This  method  of  dealing 
with  the  pedicle  is  carried  out  in  the  following  way  : — 
As  soon  as  the  tumour  is  removed  the  pedicle  is  secured 
in  a  cautery  clamp  and  screwed  up  tightly.  The  portion 
of  the  pedicle  on  the  distal  side  of  the  clamp  is  then 
divided  by  a  cautery  iron  at  a  dull  red  heat  :  the  cauteri- 
sation is  performed  slowly  and  completely.  The  clamp 
is  then  cautiously  relaxed,  and  should  any  spot  bleed  the 
clamp  is  screwed  up  again  and  the  cautery  re-applied. 
When  the  clamp  is  finally  released  it  has  a  shrivelled, 
translucent,  parchment-like  appearance.  It  then  retreats 
into  the  abdominal  cavity.  The  time  occupied  in 
cauterising  a  pedicle  varies  from  five  to  ten  minutes. 

This  method  has  been  brilliantly  successful  in  the 
hands  of  Keith,  but  the  ease  and  rapidity  with  which  a 
pedicle  is  ligatured  have  caused  the  ligature  to  be  almost 
universally  employed. 

Having  safely  disposed  of  the  pedicle,  any  blood 
that  has  found  its  way  into  the  peritoneal  cavity  is  now 


Counting  the  Sponges.  439 

carefully  removed  by  gentle  sponging.  The  surgeon 
then  examines  the  remaining  ovary  :  should  it  be  found 
obviously  diseased,  he  removes  it.  Partial  removal  of 
a  diseased  ovary,  advocated  by  a  few,  is  open  to  many 
objections.  A  small  clean  flat  sponge  is  now  placed 
over  the  intestines  which  are  in  relation  with  the  wound. 
This  serves  to  prevent  blood  gaining  access  to  the  peri- 
toneal cavity  which  may  escape  from  the  wound  or  needle 
punctures,  and  prevents  the  threads  from  getting  entangled 
in  the  intestines  or  omentum.  Instructions  should  now 
be  given  to  coiuit  the  sponges  a?id  forceps.  The  sutures 
are  now  inserted ;  for  this  purpose  silk,  plain  or  waxed, 
or  silkworm  gut  may  be  used.  Most  surgeons  prefer 
silk.  A  stout  needle  is  attached  to  each  end  of  the 
thread,  as  this  enables  the  needle  to  be  passed  from  the 
peritoneum  towards  the  skin  on  each  side  of  the  wound. 
It  is  best  to  commence  at  the  upper  angle  of  the  wound. 
The  sutures  should  be  inserted  at  intervals  of  half  an  inch, 
and  must  be  parallel  to  each  other.  In  passing  the 
suture  the  needle  should  traverse  the  peritoneum,  then 
each  layer  of  the  aponeurosis  of  the  rectus  muscle,  and 
lastly  the  integument,  the  needle  emerging  about  a 
quarter  of  an  inch  from  the  margin  of  the  wound.  When 
sufficient  threads  have  been  inserted  they  are  gathered 
up  on  each  side  of  the  wound  and  grasped  with  forceps, 
or  each  suture  may  be  secured  temporarily  with  forceps 
as  soon  as  it  is  passed. 

Before  proceeding  to  fasten  the  sutures  they  should 
be  carefully  drawn  aside,  and  a  sponge  in  the  s^Donge- 
forceps,  or  in  a  holder,  carefully  introduced  into  the 
recto-vaginal  pouch.  This  tell-tale  sponge  indicates  the 
existence  of  oozing,  and  if  it  comes  up  quite  clean  all 
is  well,  and  the  wound  may  be  closed.  Should  the  sponge 
return  bloody,  the  pedicle  is  examined  and  any  bleeding 
point  immediately  secured.     This  is  an  important  rule  : — 


440  Ovarian  and  Tubal  Diseases 

Never  close  the  abdommal  woimd  without  usi7ig  the  tell-tale 
sp07ige  even  in  what  appears  to  he  the  simplest  case. 

Some  of  the  sutures  are  now  tied^  and  then  the 
protecting  sponge  is  withdrawn  and  the  wound  is  com- 
pletely closed.  The  mutual  pressure  of  the  cut  surfaces 
restrains  haemorrhage,  and  it  is  never  needful  to  ligature 
vessels  in  the  wounds.  The  skin  edges  are  carefully 
co-apted,  and  should  they  gape,  a  few  superficial  sutures 
may  be  inserted.  In  tying  the  deep  sutures  the  aim 
should  be  to  fasten  them  with  sufficient  firmness  to  keep 
the  parts  in  apposition  j  excessive  tightness  interferes 
with  union.  The  ends  of  the  sutures  are  cut  away  and 
the  wound  is  dressed.  The  simplest  mode  of  dressing, 
and  one  I  employ  with  the  happiest  results,  is  to  apply 
a  double  fold  of  boric  lint  to  the  wound  :  over  this  is 
arranged  a  pad  of  charpie,  and  then  two  or  three  folds 
of  absorbent  cotton-wool.  A  flannel  binder  is  then 
adjusted,  and  fastened  firmly  with  safety-pins.  This 
dressing  is  rarely  touched  before  the  seventh  day,  and 
then  alternate  sutures  are  removed.  The  remainder  are 
withdrawn  two  days  later,  and  the  wound  is  usually  found 
soundly  healed. 

If  it  is  the  fashion  of  the  surgeon  to  employ  anti- 
septic rather  than  aseptic  principles,  he  will  use  carbolic 
gauze,  oil-silk,  or  other  materials,  according  to  the 
principles  of  true  Listerism.  When  the  case  is  one  in 
which  the  surgeon  deems  it  necessary  to  resort  to  drainage^ 
the  final  stages  of  the  operation  are  somewhat  modified. 
i^See  chapter  xl.) 

It  is  not  too  much  to  state  that  success  in  ovariotomy 
depends  in  a  large  measure  upon  decision  on  the  part  of 
the  surgeon  ;  he  should  also  exercise  care  even  in 
apparently  trifling  matters  of  detail ;  there  should  be 
no  unnecessary  manipulation  of  the  parts,  no  fussiness, 
but  extreme  gentleness  and  the  most  scrupulous  cleanliness^ 


Incomplete  Ovariotomy.  441 

and  the  operation  should  be  conducted  with  as  much 
expediticm  as  is  consistent  with  thoroughness.  The  exhi- 
bition of  these  quaUties  ahvays  indicates  an  experienced 
and  successful  operator. 

Clumsy  and  injudicious  operators  always  attribute 
their  failures  to  nurse,  sponges,  surroundings^  or  even  the 
patient.  All  such  should  remember  what  Keith"^  wrote  : 
"  For  my  own  part,  when  a  case  goes  wrong  after  an 
operation,  I  have  seldom  to  look  far  beyond  myself  for 
the  cause  of  failure  :  something  done,  something  not 
done.  This  is  a  lesson  hard  to  learn.  We  blame 
persons,  things,  accidents,  and  circumstances  rather  than 
ourselves." 

Iiicoiiiplete  ovariotomy. — In  the  course  of  an 
ovariotomy  the  operator  may  find  it  impossible  to  remove 
the  cyst,  in  consequence  of  its  deep  and  firm  adhesion  to 
important  structures  in  the  pelvis.  The  hopelessness  of 
the  task  may  not  be  appreciated  until  after  the  con- 
tents of  the  cyst  have  been  evacuated.  Under  such 
conditions  the  only  course  left  to  the  surgeon  is  to 
stitch  the  edges  of  the  opening  he  has  made  in  the  cyst 
to  the  margins  of  the  abdominal  incision,  and  leave  it 
to  drain.  This  was  at  one  time  the  usual  method  of 
treating  ovarian  cysts.  It  has  been,  and  w^ith  good 
reason,  long  abandoned  as  a  routine  proceeding. 

When  a  cyst  has  been  in  this  way  stitched  to  the 
abdominal  wound,  the  walls  of  the  cyst  gradually 
suppurate,  and  the  cyst  is  converted  into  an  abscess  cavity. 
Sometimes  it  will  shrink  to  very  small  proportions,  but 
rarely  closes  completely. 

I  have  seen  this  method  practised  with  irremovable 
multilocular  oophoritic  cysts  and  with  dermoids.  As  a 
rule,  the  patients  die  slowly,  exhausted  by  the  continual 

*  Brit.  Med.  Join-?ial,  1878,  vol.  ii.  p.  590. 


442  OVARIAN  AND    TUBAL    DISEASES. 

discharge  of  pus,  months   and  in   some   cases  two  and 
even  three  years  after  the  operation. 

The  after-treatmeiit. — The  patient  is  returned  to 
bed  with  gentleness,  to  avoid  vomiting  ;  a  pillow  is  placed 
under  her  knees,  and  if  there  is  evidence  of  much  shock 
a  hot-water  bottle  should  be  applied  to  the  feet,  remem- 
bering that  the  patient  is  unconscious,  or  she  will  run  the 
chance  of  having  the  feet  blistered  unless  the  nurse 
exercises  due  watchfulness. 

In  a  s'  art  time  the  patient  recovers  consciousness 
and  complains  of  pain  ;  as  a  rule  there  is  vomiting,  the 
result  of  the  anaesthetic,  and  thirst. 

When  the  pain  is  very  severe  a  quarter  of  a  grain  of 
morphia  may  be  given,  in  the  form  of  a  suppository,  a 
few  hours  after  the  operation  ;  should  the  pain  continue, 
this  may  be  repeated  in  the  course  of  six  hours.  In 
many  cases  no  opium  is  required,  and  the  routine  use  of 
this  drug  is,  to  say  the  least,  injudicious. 

Vomiting'. — This  result  of  the  anaesthetic  is  some- 
times troublesome.  It  is  best  avoided  by  keeping  the 
stomach  empty  for  twenty-four  hours.  To  relieve  the 
thirst  the  patient  is  allowed  to  wash  the  mouth  with  cold 
water,  but  on  no  account  to  swallow  it. 

Young  patients  easily  bear  this  apparently  prolonged 
fast,  but  in  the  case  of  patients  exhausted  by  disease, 
prolonged  operation,  or  loss  of  blood,  abstinence  of 
this  character  would  be  disastrous.  Under  such  condi- 
tions a  nutrient  enema,  consisting  of  beef-tea  or  milk, 
with  a  small  quantity  of  brandy,  administered  at  intervals 
of  six  hours,  is  most  useful.  Should  it  be  necessary  to 
prescribe  opium  in  such  cases,  twenty  drops  of  Battley's 
solution  may  be  added  to  one  of  the  enemata. 

At  the  end  of  twenty-four  hours  small  quantities  of 
barley-water  or  milk  and  water  should  be  given,  and 
if   retained,    then    milk   is   given  more  frequently,    and 


After-  Trea  tment.  443 

subsequently  beef-tea.  If  at  the  end  of  three  days  no 
untoward  symptoms  arise,  chicken  jelly,  pounded  chicken, 
or  boiled  fish  is  allowed,  and  the  patient  soon  gets  well 
enough  to  take  convalescent  diet.  No  precise  rule  can 
be  formulated  for  dieting  patients  :  some  cannot  take 
milk,  others  reject  beeftea.  My  custom  is  to  keep 
them  on  milk  diet  for  three  days,  and  if  there  is  no 
vomiting,  then  try  solids  cautiously.  When  vomiting  is 
troublesome  with  liquid  diet,  this  may  be  suspended  for 
several  hours,  and  nutrient  enemata  substituted. 

When  vomiting  continues  more  than  twenty-four 
hours  after  an  operation^  especially  when  accompanied 
by  increased  frequency  of  pulse  and  distension  of  the 
belly,  it  is  usually  an  unfavourable  sign.  Slight  vomiting, 
with  no  distension  and  a  normal  pulse  rate,  need  not 
occasion  alarm. 

The  bladder. — For  the  first  twenty-four  hours  the 
urine  is  drawn  off  by  the  nurse  by  means  of  a  soft  catheter. 
This  instrument,  when  not  in  actual  use,  must  be  kept  in 
clean  water  or  mild  antiseptic  solution.  It  must  be 
thoroughly  washed  each  time  it  is  used.;  in  passing  it 
into  the  bladder  the  nurse  should  wipe  away  the  mucus 
around  the  urethral  orifice,  so  as  to  avoid  carrying  infection 
into  the  bladder.  Even  with  a  thoroughly  trustworthy 
nurse  it  is  well  to  be  suspicious  of  the  catheter,  and  it  is 
a  safe  plan  to  encourage  the  patient,  after  the  first  day,  to 
pass  water  by  her  own  efforts.  Unfortunately,  many 
women  cannot  micturate  when  lying  on  their  backs. 
Cleanliness  and  care  with  the  catheter  must  be  strictly 
enforced  ;  cystitis  causes  much  misery. 

Temperature. — This  should  be  observed  every  four 
or  six  hours,  and  duly  recorded  in  the  note-book.  The 
first  record  after  the  operation  is  usually  sub-normal,  and 
in  twelve  hours  becomes  normal,  and  may  even  be  raised 
half  a  degree.     During  the  first  twenty-four  hours  it  may 


444  Ovarian  and  Tubal  Diseases. 

ascend  to  loo  without  causing  alarm  ;  beyond  this,  es- 
pecially if  accompanied  by  a  rapid  pulse,  an  anxious  face, 
and  distended  belly,  it  is  sufficient  to  make  the  surgeon 
anxious.  A  temperature  of  ioi°  or  102°,  unaccompanied 
by  other  unfavourable  symptoms,  is  not  a  cause  for 
alarm  unless  maintained. 

Pulse. — This  is  a  valuable  guide,  and  even  more 
trustworthy  than  the  temperature.  When  the  pulse  re- 
mains steady  and  full  there  is  no  cause  for  alarm.  When 
it  increases  in  frequency  to  120  or  130  or  more  beats  in 
the  minute,  is  thin  and  thready,  then  there  is  danger,  even 
with  the  temperature  only  slightly  raised. 

Bisteiision  of  tlie  afedoiiieii  is  due  to  the  accu- 
mulation of  gas  in  the  intestines  ;  it  is  usually  first  observed 
in  the  transverse  colon.  It  occasions  in  some  cases  much 
discomfort  and  it  is  not  always  easy  to  relieve  it.  The 
passage  of  the  rectal  tube  is  useful,  or  a  simple  enema ; 
a  saline  purge  is  recommended  by  some  surgeons. 

Metrostaxis. — After  operations  for  the  removal  of 
both  ovaries  and  tubes,  blood  sometimes  escapes  from  the 
uterus  and  simulates  menstruation.  It  usually  occurs 
within  the  first  forty-eight  hours  after  the  operation. 
Metrostaxis  occurs  in  or  about  one  half  the  cases,  and 
has  nothing  to  do  with  menstruation. 

Bowels. — At  the  end  of  four  or  five  days  the  bowels 
will  occasionally  act  of  their  own  accord  ;  usually,  how- 
ever, it  is  necessary  to  use  a  simple  enema,  and  this  is,  in 
the  majority  of  cases,  quite  efficient.  When  opium  has 
been  freely  administered,  still  more  active  measures  may 
be  required. 

Sutures. — On  the  seventh  or  eighth  day  the  sutures 
will  require  removal.  It  is  a  good  plan  to  allow  two  to 
remain  (taking  care  not  to  leave  those  that  are  causing 
irritation)  twenty-four  hours  longer.  After  removing  the 
sutures  a  broad  band  of  adhesive  plaster  should  be  firmly 


After-  Trea  tment.  445 

fastened  across  the  abdomen,  with  a  good  grip  on  each 
hip.  This  precaution  is  necessary,  as  an  incautious  or 
violent  movement,  such  as  coughing  or  straining,  may 
cause  the  skin  edges  of  the  wound  to  gape. 

Should  suppuration  or  stitch-hole  abscesses  occur — 
and  these  are  rare — they  must  be  treated  on  general 
principles.  Erysipelas  may  attack  the  abdominal  wound, 
and  retard  convalescence. 

Bed  sores  may  give  trouble  after  ovariotomy  in  an 
elderly  and  enfeebled  patient,  as  after  any  other  surgical 
procedure  which  requires  the  patient  to  remain  for 
several  consecutive  days  upon  her  back.  With  due 
care  and  watchfulness  on  the  part  of  the  nurse  a  bed 
sore  should  rarely  occur. 

The  cicatrix. — In  nearly  all  instances  the  abdominal 
wound  rapidly  heals.  Occasionally  a  case  is  met  with  in 
which,  after  removal  of  the  stitches,  the  wound  has  gaped, 
and  the  edges  of  the  incision  re-open  down  to  the  peri- 
toneum. This  membrane  fortunately  rapidly  unites,  so 
that  in  cases  where  the  wound  does  not  repair  the  peri- 
toneum serves  to  restrain  the  abdominal  contents.  I 
once  made  2iJ}0st  viorteni  examination  on  a  woman  seven 
weeks  after  an  oophorectomy,  in  which  there  was  not  the 
slightest  attempt  at  union  in  the  wound  outside  the  peri- 
toneum. With  very  rare  exceptions,  the  parietal  wound 
heals  rapidly,  and  the  chief  trouble  is  to  restrain  the 
patient  from  moving  about  too  quickly.  Care  in  this 
respect  is  very  necessary,  otherwise  the  cicatrix  yields, 
and  a  troublesome  hernia  is  the  result.  After  abdominal 
section,  even  where  the  wound  heals  as  quickly  as  is 
possible,  the  patient  should  be  kept  confined  to  bed 
twenty-one  days  or  a  month,  and  not  allowed  to  get  up 
at  the  end  of  that  time  unless  she  wears  a  comfortable 
and  correctly-fitted  abdominal  belt.  This  she  should  be 
instructed  to  wear  for  at  least  a  year ;  and  during  that 


446  Ovarian  AND   Tubal  Diseases. 

time  the  patient  should  be  strongly  warned  against 
moving  about  without  it.  Even  at  the  end  of  the  year, 
should  the  scar  show  indications  of  yielding,  the  use  of 
the  belt  should  be  continued. 

Many  causes  have  been  suggested  for  a  yielding  cica- 
trix, such  as  suppuration  of  the  wound,  inserting  the 
sutures  too  far  apart,  failure  to  include  all  the  tissues 
of  the  abdominal  wall  in  the  sutures,  or  laborious 
occupation. 

My  own  experience  has  been  that  in  those  cases 
which  unite  rapidly,  and  the  patient  when  allowed  to  get 
about  too  early  has  neglected  the  use  of  the  belt,  the  scar 
yields  most.  Since  I  have  adopted  the  plan  of  keeping 
them  in  bed,  even  the  most  favourable  cases,  from  twenty- 
one  to  twenty-eight  days,  and  insisted  on  the  use  of  the 
belt,  this  complication  has  ceased  to  cause  me  trouble. 

Cases  have  been  described  in  which  the  abdominal 
cicatrix  has  become  the  seat  of  cancer.  Unfortunately, 
those  who  have  recorded  such  conditions  have  not  forti- 
fied their  statements  by  descriptions  of  the  histological 
characters  of  the  so-called  cancer. 


447 


CHAPTER     XXXIX. 

OOPHORECTOMY. 

Oopliorectoniy  signifies  the  removal  through  an 
abdominal  incision  of  the  ovaries  and  Fallopian  tiibes^for 
affections  maiTily  inflammatory  ;  also  the  removal  of  healthy 
ovaries  and  tubes  to  anticipate  the  menopause. 

The  term  is  open  to  much  criticism  ;  so  are  many 
other  names  in  common  use  in  surgery. 

The  inflammatoiy  conditions  in  which  it  is  employed 
are  : — 

1.  Pyosalpinx  and  tubo-ovarian  abscess. 

2.  Hydrosalpinx. 

3.  Tubercular  salpingitis. 

4.  Ovarian  abscess. 

It  is  employed  to  anticipate  the  menopause  in  : — 
Uterine  myomata. 

This  is  also  the  principle  on  which  the  operation  is 
based  for  the  relief  of  such  conditions  as  : — 

1.  Hystero-epilepsy. 

2.  Epilepsy. 

3.  Some  forms  of  insanity. 

4.  Dysmenorrhoea,   unassociated   with    demonstrable 

disease  of  the  ovaries. 
The  operation  has  been  performed  chiefly  on  em- 
pirical grounds  in  : — 

1.  Watery  discharges  from  the  uterus.* 

2.  Ill-developed  ovaries.  | 

3.  Osteomalacia. t 

*  Skene  Keith  :  Lancet^  1891,  vol.  i.  p.  985. 

t  Dr.  William  Duncan  :  Lancet,  1891,  vol.  i.  p.  187. 

\  Hofmeier  :   Cenb'alblatt  fur  Gyn.,  March  21st,  1891. 


448  Ovarian  and  Tubal  Diseases. 

Other  conditions  treated  by  oophorectomy  are  : — 

r  myoma, 

1.  Tumours  of  the  Fallopian  tubes  \  adenoma, 

\  carcinoma. 

2.  So-called  prolapsed  ovary. 

3.  Early  tubal  pregnancy. 

4.  Apoplexy  of  the  ovary. 

For  the  performance  of  oophorectomy  the  patient  is 
prepared  in  the  same  manner  as  for  ovariotomy ;  and  the 
instruments  needed  are  much  the  same,  except  that  the 
large  trocar  will  not  be  required.  As  a  rule,  the  incision 
is  longer  than  in  simple  ovariotomy,  but  the  stages  are 
identical  until  the  peritoneal  cavity  is  opened.  The 
subsequent  stages  of  the  proceeding  are  different.  Not 
infrequently  the  surgeon  finds,  after  dividing  the  peri- 
toneum, the  omentum  adherent  to  'the  parietes,  and  it  is 
necessary  to  separate  it  very  carefully  and  cautiously,  in 
order  to  gain  access  to  the  pelvic  cavity.  He  then  seeks 
the  ovary  and  tube  of  one  or  other  side ;  should  he  meet 
with  difficulty  in  finding  them,  it  is  a  useful  plan  to  ascer- 
tain the  position  of  the  uterus,  and  use  that  as  a  guide. 
In  many  cases  the  organs  are  recognised  without  the 
slightest  difficulty,  and  are  easily  drawn  up  to  the  level  of 
the  wound  ;  in  others,  recognition  of  the  parts  is  difficult, 
and  when  their  position  is  made  out,  they  may  be  so  bound 
down  by  dense  adhesions  that  they  cannot  be  raised  to 
the  level  of  the  incision.  On  meeting  dense  tough  ad- 
hesions it  is  usual  to  insert  a  large  flat  sponge,  in  order 
to  exclude  the  intestines  from  the  pelvis,  and  then  let  the 
assistant  carefully  keep  the  wound  open  by  means  of 
broad  retractors.  In  this  way  it  will  be  possible  to  see 
the  parts,  and  if  necessary,  illuminate  the  recesses  of  the 
pelvis  by  means  of  a  reflector  or  electric  light,  which 
should  exist  in  every  well-appointed  operating-theatre. 

When  the  ovary  and  tube  are  sufficiently  freed  they 


Oophorectomy.  449 

are  seized  with  a  pair  of  large  forceps.  None  are  more 
useful  for  this  purpose  than  those  known  as  ovum  or 
sponge-forceps.  The  surrounding  parts  are  protected  by 
sponges,  and  the  pedicle  transfixed  by  means  of  a  pedicle- 
needle  or  an  ordinary  needle  in  handle,  the  greatest  care 
being  exercised  that  the  instrument  does  not  transfix  or 
prick  a  piece  of  bowel  which  may  be  lying  near  or 
adherent  to  the  pedicle.  The  silk  is  tlien  tied  in  the 
same  manner  as  in  ovariotomy.  At  the  time  of  tying  the 
ligature  the  assistant  gently  relaxes  the  grip  of  the  for- 
ceps, and  the  knot  will  be  felt  to  tighten. 

In  many  cases,  especially  with  a  well-trained  and 
experienced  assistant,  the  forceps  are  unnecessary,  as  he 
will  be  able  to  hold  the  parts  with  his  thumb  and  fore- 
finger. 

When  the  tissues  are  soft,  from  long-standing  inflam- 
mation, a  clumsy  assistant  may,  by  injudiciously  dragging 
on  the  forceps,  tear  them.  Unless  the  surgeon  and 
assistant  are  accustomed  to  work  together,  the  surgeon 
needs  to  be  on  his  guard  against  excessive  zeal  on  the 
part  of  the  latter. 

When  a  distended  tube  exists,  and  the  fluid  may  be 
pus,  caution  in  separating  adhesions  and  raising  it  is  very 
necessary ;  and  in  spite  of  care  and  skill,  it  happens  that 
just  at  the  moment  of  raising  the  tube  into  view,  the 
wall  of  the  cavity  yields  and  the  fluid  escapes.  This 
constitutes  an  additional  reason  for  completely  isolating 
the  parts  by  means  of  sponges.  The  application  of  the 
ligature  is  often  a  source  of  anxiety :  the  infiltrated 
tissues  are  so  soft  in  some  cases,  that  any  undue  force  or 
jerking  of  the  Hgature  will  tear  them,  and  necessitate 
re-transfixion. 

.  When  the  ligature  is  satisfactorily  applied  the  distal 
parts  are  cut  away  w^ith  scissors ;  the  cut  surface  is  then 
examined,  to  ascertain  that  no  inflamed  or  suppurating 

D  D 


45 O  OVARIAN  AND    TUBAL    D/S EASES. 

tissue  is  left  behind.  If  this  is  the  case,  and  it  cannot 
be  dissected  out  without  endangering  the  Hgatures,  the 
parts  should  be  re-transfixed  and  tied. 

When  it  has  been  found  necessary  to  remove  the 
ovary  and  tube  on  one  side  for  inflammatory  disease, 
experience  teaches  the  necessity  of  removing  the  parts 
on  the  opposite  side,  or  the  operation  will  fail  to  be 
beneficial. 

The  remaining  steps  of  the  operation  are  conducted 
on  the  same  principles  as  in  ovariotomy. 

When  oophorectomy  is  performed  for  the  purpose  of 
artificially  inducing  the  menopause  in  cases  of  uterine 
myomata,  it  may  occasionally  be  a  relatively  easy  opera- 
tion ;  but  with  very  large  tumours  it  is  very  difficult,  and 
often  impossible,  to  remove  completely  the  ovaries  and 
tubes. 

The  great  danger  of  this  operation  with  large  tumours 
is  due  to  several  circumstances.  In  the  first  place,  the 
broad  ligaments  and  tubes  are  so  stretched  that  when  the 
parts  are  tied  and  cut  away,  the  tension  upon  the  ligatures 
is  so  great  that  they  slip  off.  When  this  happens  in  the 
course  of  the  operation,  it  is  sometimes  very  difficult  to 
discover  and  secure  the  vessels,  and  in  very  many  cases 
it  has  been  necessary  to  perform  hysterectomy  to  control 
the  bleeding.  Should  the  accident  happen  after  the 
patient  has  been  returned  to  bed,  it  has  in  most  cases  a 
fatal  termination. 

Not  infrequently  the  ovaries  and  tube  of  one  side  are 
free,  and  easily  removed,  but  those  of  the  opposite  side 
are  so  embedded  in  the  tumour,  or  the  ovary  may  be 
elongated  into  a  long  rounded  cord  and  embedded  in  the 
midst  of  a  formidable  plexus  of  veins,  that  its  removal 
is  impossible.  This  will  nullify  the  operation,  for  the 
presence  of  even  a  portion  of  ovarian  tissue  is  sufficient 
to  ensure  the  persistence  of  menstruation.     In  carrying 


Sa  LP  I  NCOS  TOM  V.  4  5  I 

out  the  necessary  manipulations  within  the  abdomen 
every  care  must  be  exercised  to  prevent  the  least  injury 
to  the  capsule  of  the  tumour,  for  they  bleed  very  freely 
even  from  the  least  puncture  ;  as  the  tissues  are  exceed- 
ingly tense,  it  is  no  easy  matter  to  arrest  the  haemorrhage, 
except  by  the  performance  of  hysterectomy. 

SalpiiigostOMiy  is  a  conservative  operation,  intro- 
duced by  Skutsch,*  of  Jena.  It  consists  in  removing 
the  fluid  contents  of  a  distended  Fallopian  tube  by 
means  of  a  Pravaz  syringe,  to  ascertain  its  freedom  from 
pus.  The  occluded  ostium  is  re-opened,  the  fluid  allowed 
to  escape,  and  a  piece  of  the  tubal  wall  cut  away.  The 
mucous  and  serous  membranes  are  then  united  along 
the  margin  of  the  artificial  opening  by  fine  silk  thread. 
A  sound  is  then  passed  from  the  tube  into  the  uterus. 

The  sequelae  of  oophorectomy  are  considered,  with 
those  of  ovariotomy,  in  chapter  xli.  The  remote  effects  of 
the  removal  of  the  ovaries  are  discussed  in  chapter  xlii. 

*  Centralblatt  fiir  Gyn.,  1889. 


D  D    2 


452 


CHAPTER    XL. 

IRRIGATION    AND     DRAINAGE. 

Iriig-atioii  of,  or,  as  it  is  frequently  termed,  fliisliin^?. 

the  peritoiieuiM  is  an  exceedingly  useful  proceeding 
when  there  has  been  an  escape  of  fluid,  septic  material, 
or  extensive  haemorrhage  previous  to  or  during  the  per- 
formance of  abdominal  section.  The  principle  consists 
simply  in  washing  out  the  peritoneal  cavity  with  warm 
water ;  the  particular  method  employed  matters  but 
little. 

In  hospital  practice  the  method  I  employ  is  the  follow- 
ing : — The  irrigating  vessel  is  an  ordinary  bedroom  can, 
capable  of  holding  two  gallons  of  fluid.  In  the  front 
part  of  it,  two  inches  from  the  bottom,  there  is  a  stop- 
cock connected  with  an  indiarubber  delivery-tube  i|m. 
in  length  and  2  cm.  in  diameter.  When  an  abdomen 
requires  irrigation,  the  can  is  filled  with  plain  water  at 
a  temperature  of  110°  to  115°  Fahr.,  determined  by  a 
thermometer  kept  for  the  purpose.  It  is  necessary  to  be 
particular  in  this  respect,  and  never  guess  at  the  heat  of 
the  water  according  to  the  sensations  imparted  to  the 
hands  of  the  nurse  or  assistant.  The  patient  is  then 
turned  a  little  to  one  side,  and  a  dresser  or  nurse  elevates 
the  can,  and  a  steady  forcible  stream  flows  through  the 
tube.  The  surgeon  introduces  his  left  hand  into  the 
abdomen,  and  restrains  the  intestines  from  being  carried 
through  the  wound  with  the  outflowing  stream.  The 
water,  by  means  of  the  flexible  tube,  is  conveyed  to  all 
parts  of  the  abdomen,  whilst  the  movements  of  the  left 


Irrigation.  453 

hand  among  the  viscera  prevent  clots  from  being  retained 
in  the  various  recesses.  The  tube  must  be  directed 
deeply  in  the  recto-vaginal  pouch,  so  as  to  wash  out 
blood  lying  in  that  situation  and  also  in  the  iliac  fossae. 
The  water,  which  was  at  first  discoloured  by  blood,  pus, 
or  serum,  according  to  circumstances,  quickly  comes  away 
clear,  unless  there  is  oozing  or  free  bleeding.  In  this 
case,  a  little  experience  soon  enables  the  surgeon  to  tell 
if  it  be  of  any  extent,  and  he  at  once  seeks  for  the  spot 
whence  the  blood  comes.  As  soon  as  the  water  issues 
from  the  abdomen  as  clear  as  it  entered,  the  irrigation  is 
stopped,  and  the  retained  fluid  is  quickly  taken  up  with 
sponges. 

The  reason  for  turning  the  patient  to  one  side  is  to 
allow  the  water  to  flow  to  that  side,  and  it  is  easily  caught 
in  some  convenient  receptacle.  The  large  sheet  of  water- 
proof on  which  the  patient  is  placed  at  the  commence- 
ment of  the  operation  keeps  the  bed  dry,  and  is  easily 
converted  into  a  trough  to  collect  any  water  which  may 
escape  the  smaller  receptacle  held  by  the  assistant,  and 
direct  it  into  a  foot-pan  under  the  bed.  Irrigation  may 
in  this  way  be  accomplished  quickly,  and  without  fuss  or 
causing  slop  around  the  table. 

When  the  surgeon  is  satisfied  that  the  parts  are  clean, 
and  he  has  sponged  up  the  fluid  in  the  pelvis,  he  should 
lodge  two  large  sponges  in  the  recto-vaginal  pouch  to 
soak  up  fluid  as  it  trickles  down  from  the  loins  or  from 
among  the  coils  of  intestines,  whilst  he  inserts  the  sutures 
in  the  wound.  By  the  time  he  has  done  this  the  peri- 
toneum is  usually  dry,  and  he  removes  the  sponges  and 
closes  the  wound,  unless  it  is  a  case  demanding  drain- 
age. 

In  cases  occurring  in  private  houses  where  irrigation 
is  necessary,  the  water  may  be  poured  into  the  belly  from 
a  large  jug,  taking  care  that  it  enters  in  a  steady,  full,  but 


454  Ovarian  and  Tubal  Diseases. 

not  forcible  stream.  The  peritoneum  may  also  be  ad- 
mirably irrigated  by  filling  a  large  ewer  with  water,  and 
using  a  long  and  wide  piece  of  drainage-tube  on  the 
syphon  principle. 

In  this,  as  in  all  other  departments  of  surgery,  much 
may  be  accomplished  by  the  exercise  of  a  little  common 
sense.  It  should  be  mentioned  that  when  the  surgeon 
uses  sublimate,  or  similar  solutions,  the  reservoir  should 
be  of  glass  or  porcelain  rather  than  of  metal.  He  should 
always  remember  the  danger  necessarily  involved  by  the 
presence  of  large  quantities  of  even  weak  solutions  of 
such  a  poisonous  substance  as  perchloride  of  mercury. 

Plain  water  is  the  safest  medium  for  irrigating  the 
peritoneal  cavity. 

Irrigation  is  always  indicated  when  there  has  been 
much  oozing  from  the  separation  of  many  adhesions,  or 
an  escape  of  jjus,  or  the  presence  of  much  blood,  as  in 
rupture  of  an  ovarian  cyst,  a  gravid  tube,  or  a  tubal  abor- 
tion. The  proceeding  is  not  limited  to  the  needs  of  the 
ovariotomist,  but  is  of  great  use  when  operations  are 
undertaken  for  ruptured  viscera,  etc. 

Water  at  iio°  to  115°  is  comfortably  borne  by  the 
peritoneum,  and  at  this  temperature  it  does  not  cause 
shock,  but  cleanses  the  peritoneum,  and  acts  as  an 
admirable  haemostatic  to  oozing  surfaces. 

Irrigation  does  not  of  ?iecessity  entail  the  subsequent  use 
of  a  drainage-tube^  and  in  7?ia?iy  instances  renders  its 
employment  unnecessary. 

Drainag-e. — After  the  removal  of  an  adherent 
tumour,  and  the  various  bleeding  vessels  have  been  duly 
ligatured,  it  occasionally  happens  that  blood  oozes  into 
the  peritoneal  cavity  from  a  number  of  capillary  vessels 
too  small,  or  in  situations  inaccessible,  to  permit  the 
application  of  a  ligature.  Such  oozing  is  frequently 
arrested  by  irrigation.     AVhen  the  surgeon  apprehends 


Drainage.  455 

during  the  reaction  a  recurrence  of  the  oozing,  he  em- 
ploys a  drainage-tube. 

The  tubes  employed  for  this  purpose  are  made 
of  glass,  and  of  different  sizes.  Those  most  frequently 
used  are  the  patterns  introduced  by  Koeberle  and 
Keith. 

Koeberle's  drainage-tube  is  shaped  like  a  test-tube, 
except  that  it  tapers  somewhat,  and  is  perforated  through- 
out its  length.  The  smooth  rounded  end  prevents  damage 
to  the  peritoneum  at  the  bottom  of  the  pelvis  ;  the  fluid 
enters  the  tube  through  the  perforations. 

Keith's  drainage-tube  is  the  most  useful ;  it  is  open 
at  the  bottom  as  well  as  at  the  top,  and  the  perforations 
only  involve  the  lower  third  of  the  tube.  Near  the  orifice 
of  the  tube  there  is  a  projecting  ridge.  When  the 
surgeon  decides  to  drain,  he  selects  a  tube  which  will 
reach  to  the  bottom  of  the  recto-vaginal  pouch,  whilst 
the  rim  at  the  upper  part  of  the  tube  lies  in  contact  with 
the  skin,  and  prevents  the  tube  from  slipping  into  the 
abdomen. 

The  tube  is  introduced  in  the  following  manner : 
The  left  hand  is  passed  into  the  recto-vaginal  pouch  and 
the  intestine  held  back,  whilst  with  the  right  hand  the 
tube  is  passed  downwards  until  its  end  rests  upon  the 
floor  of  the  pelvis,  and  not  upon  a  coil  of  gut  :  the  tube 
should  lodge  in  the  lower  angle  of  the  wound,  between  the 
last  two  sutures.  The  wound  is  then  closed  in  the 
ordinary  manner.  A  piece  of  indiarubber  cloth  is  fixed 
on  to  the  tube,  and  a  small  conical  antiseptic  sponge  placed 
over  its  orifice,  and  the  four  corners  of  the  cloth  are  folded 
together  ;  this  collects  fluid  escaping  from  the  tube,  and 
keeps  the  dressing  dry.  It  is  not  necessary  to  cover  the 
end  of  the  tube  in  this  way.  Frequently  I  adjust  a  piece 
of  waterproof  material  over  the  tube,  and  loosely  fix  a 
piece    of    absorbent    cotton-wool    in    its    orifice.       The 


45^  OrAR/Aiv  AND  Tubal  Diseases. 

nurse  examines  the  tube  from  time  to  time,  and  as  the 
fluid  accumulates  she  empties  it  by  means  of  a  glass 
syringe,  armed  with  a  piece  of  narrow  flexible  tubing. 
The  tubing  is  inserted  three-quarters  of  the  distance 
down  the  drainage-tube,  and  as  the  nurse  exhausts  the 
syringe  the  contents  of  the  tube  flow  into  it.  The 
greatest  care  must  be  exercised  to  keep  this  syringe  and 
tubing  clean ;  when  not  being  actually  used,  it  should 
be  kept  immersed  in  whatever  antiseptic  solution  the 
surgeon  selects. 

For  the  first  few  hours  the  tube  requires  frequent 
attention,  especially  when  irrigation  has  been  resorted  to. 
The  fluid  first  evacuated  is  deeply  stained  with  blood, 
but  gradually  gets  of  a  lighter  tint  and  diminishes  in 
quantity. 

During  the  first  twelve  hours  several  ounces  of  blood- 
stained fluid  may  require  removal  through  the  tube. 
During  the  succeeding  twelve  hours  perhaps  only  two 
ounces  will  be  withdrawn,  and  on  the  second  day 
perhaps  only  a  few  drachms.  The  tube  should  be 
then  removed.  It  is  impossible  to  formulate  precisely 
the  length  of  time  the  drainage-tube  should  be  retained 
t7i  situ.  In  some  cases  twenty-four  hours  are  long 
enough,  whilst  others  will  require  it  sixty  or  more 
hours. 

The  following  simple  rules  may  serve  as  a  guide 
to  those  who  have  had  little  or  no  experience  of 
drainage  : — 

1.  As  long  as  the  fluid  collects  in  the  tube  and  is 

blood-stained,  drainage  must  be  continued. 

2.  When  the  fluid  which  rises  in   the  tube    is    free 

from  blood  or  pus,  remove  the  tube. 

3.  When   the  fluid  accumulates  in  the  tube  at  the 

rate  of  an  ounce  in  twelve  hours,  it  may  be 
dispensed  with. 


Drainage.  .  457 

4.  When  the  tube  is  retained  for  more  than  one  day, 

it  should  be  moved  a  little  and  gently  rotated  : 

this  prevents  omentum  from  insinuating  itself 

into  the  perforations  of  the  tube. 

Keith's  tubes  are  useful  for  draining  the  cavity  left 

after  the  enucleation  of  sessile  cysts  and  gestation  sacs. 

Drainage  is  not  only  useful  in  enabhng  fluid  to  escape 

from  the  peritoneum,  but  it  acts  as  a  sentinel,  and  gives 

warning  of  hccmorrhage. 

When  the  abdominal  wound  is  closed,  the  patient 
returned  to  bed,  and  reaction  is  established,  the  bleeding 
may  be  free.  When  this  is  the  case,  it  escapes  through 
the  tube.  Such  conditions  must  be  treated  on  the 
principles  that  apply  to  recurrent  or  intermediate 
haemorrhage  in  other  situations — viz.  open  the  wound, 
and  search  for  the  bleeding  point  ;  this  is  rarely 
necessary. 

Drainage  is  rarely  required  after  ovariotomy.  It  is 
occasionally  advisable  when  tumours  have  been  enu- 
cleated from  the  broad  ligament,  especially  when  they 
have  burrowed  deeply.  It  is  most  frequently  needed 
after  the  removal  of  a  firmly-adherent  pyosalpinx  with 
firm  vascular  adhesions  deep  in  the  pelvis,  and  in  cases 
of  gravid  tubes  that  have  ruptured. 

The  routine  use  of  the  tube  is  to  be  condemned. 
The  disadvantages  of  drainage    must    not  be   over- 
looked.    The  chief  objections  which  have  been  urged 
are  the  following  : — 

1.  It  retards  the  union  of  the  wound. 

2.  Drainage  of  the  whole  peritoneal  cavity  is  only 

possible  during  the  first  forty-eight  hours,  as 
the  track  of  the  tube  becomes  surrounded  by 
adherent  intestine. 

3.  The  admission  of  air  may  induce  peritonitis,  or 

lead  to  the  formation  of  a  sinus. 


45 8  Ovarian  and  Tubal  Diseases. 

4.  Ligatures    are   more   likely  to   come  away   when 

drainage  has  been  employed. 

5.  The  tube  may  press  upon  and  cause  sloughing  of 

a  piece  of  gut. 

6.  Omentum    may  insinuate    itself   in   the  openings 

of  the  tube,  and  lead   to  difficulty  when  the 
tube  is  withdrawn. 

7.  A  yielding  scar  is  said  to  be  more  common  after 

the  use  of  the  tube. 

When  drainage  is  judiciously  employed,  the  good 
results  overbalance  these  disadvantages.  This  chapter 
may  be  suitably  closed  with  the  following  opinion  of 
its  usefulness  from  Keith  : — * 

"It  was  to  Koeberle  that  I  am  indebted  for  the  idea. 
He  kindly  gave  me  two  of  his  small  tubes  in  1866. 
These  were  soon  found  to  be  too  narrow  and  too  short. 
They  got  easily  choked  with  clot  or  lymph.  For  the 
last  ten  years  I  have  used  the  large  glass  tubes  now  in 
common  use.  Till  I  had  learned  in  what  cases  to  drain, 
the  tube  was  used  in  alternate  cases  of  the  severe  opera- 
tions. I  am  as  certain  as  I  am  of  my  own  existence 
that  had  I  used  them  earlier  and  oftener,  the  mortality 
would  have  been  less  by  one-third.  These  tubes  I 
supplied  to  ovariotomist  friends  in  all  parts  of  the  world, 
though  no  one  used  them,  so  far  as  I  know,  till 
attention  was  called  to  drainage  by  the  vagina  by  Dr. 
Marion  Sims — a  method  which  seems  to  me  to  be  one 
calculated  rather  to  give  rise  to  blood-poisoning  than 
to  save  the  patient  from  it.  It  is  remarkable  that  the 
only  year  in  which  the  mortality  of  the  Samaritan 
Hospital  fell  to  ten  per  cent,  was  in  1876,  when  drainage 
by  these  glass  tubes  was  first  generally  used." 

*  Brit.  Med.  Journal,  1878,  vol.  ii.  p.  591. 


459 


CHAPTER    XLl. 

THE    RISKS    AND    SEQUEL.^    OF    OVARIOTOMY    AND    ALLIED 

OPERATIONS. 

The  performance  of  ovariotomy  and  allied  operations  is 
attended  by  several  risks.  They  may  be  considered  in 
two  groups — immediate  and  remote. 

The  innnediate  risks  are — shock,  injury  to  viscera, 
haemorrhage,  peritonitis,  septicaemia. 

Sliock. — The  degree  of  shock  varies  greatly.  It  is 
rarely  seen  after  exploratory  operations,  but  the  removal 
of  even  a  small  ovarian  cyst  is  sometimes  followed  by 
profound  collapse.  It  follows  prolonged  operations  and 
enucleation  of  tumours  from  the  broad  ligament. 

Generally  the  patient  quickly  reacts  on  her  return 
to  bed.  After  severe  operations  the  patient  may  not 
regain  consciousness  for  some  hours,  and  occasionally 
collapse  terminates  in  death. 

lojiiry  to  viscera. — When  describing  the  details  of 
the  operation,  it  was  pointed  out  that  the  intestines  are 
liable  to  be  wounded  whilst  separating  adhesions.  They 
have  also  been  injured  by  the  needle  during  the  trans- 
fixion of  the  pedicle,  or  pricked  by  needles  during  suture 
of  the  abdominal  wound.  Wounds  of  the  intestines 
must  be  immediately  secured  by  means  of  a  continuous 
suture  of  fine  silk. 

The  bladder  has  been  punctured  with  the  trocar  in 
mistake  for  a  cyst.  It  should  be  closed  with  a  con- 
tinuous suture,  and  the  bladder  tested  with  milk,  or 
some  bland  fluid,  in  order  to  be  sure  that  urine  will  not 


460  Ovarian  and  Tubal  Diseases. 

leak  between  the  sutures.  The  routine  use  of  the 
catheter  before  operation  ought  to  prevent  injury  to  the 
bladder  in  abdominal  operations. 

The  ureter  has  been  injured  during  the  separation  of 
adhesions  at  the  pelvic  brim.  This  accident  has  ne- 
cessitated nephrectomy.*  Pozzif  is  of  opinion  that  the 
ureter  is  not  infrequently  wounded  during  the  removal 
of  an  abdominal  tumour.  When  the  wound  is  small,  the 
edges  should  be  brought  together  by  suture.  When 
completely  severed,  the  proximal  end  should  be  stitched 
to  the  abdominal  wound.  It  will  be  necessary  to  per- 
form nephrectomy  later,  to  save  the  patient  the  misery  of 
a  urinary  fistula.  Pozzi  reports  a  case  in  which  this  plan 
was  carried  out. 

It  has  already  been  mentioned  that  during  the 
performance  of  ovariotomy  the  uterus  may  be  gravid, 
and  the  operator,  ignorant  of  the  condition,  may  un- 
guardedly plunge  the  trocar  into  the  uterus. 

Under  such  conditions,  three  courses  are  open  to  the 
surgeon  : — (i)  Enlarge  the  incision,  empty  the  uterus, 
and  stitch  up  the  opening  in  the  uterine  wall ;  perform, 
in  fact,  Caesarean  section.  (2)  Pass  a  clamp  or  serre- 
noeud  around  the  uterus,  and  remove  it  by  w^hat  is  known 
as  Porro's  operation  (amputation  of  the  gravid  uterus), 
(3)  Sew  up  the  wound. 

Each  of  these  methods  has  been  practised  with 
success.  Sir  Spencer  Wells  |  and  Dr.  Byford,§  of 
Chicago,  have  each  reported  a  case  in  which  the  gravid 
uterus  was  punctured  with  the  ovariotomy  trocar,  in 
mistake  for  an  ovarian  cyst. 

*  Thornton  :  Med.-Chir.  Trans.,  vol,  Ixx.  p.  64,  case  335. 
t  Progres  Mtd.,    April    nth,   1891  :    "Proceedings  of  the  French 
Congress  of  Surgery."     See  a/joTait :  Diseases  of  Ovaries,  p.  282  ;  1883. 
%  Medical  Times  and  Gazette,  Sept.  30th,  1865. 
\  America7i  Journal  of  Obsteti-ics,  vol.  xii.  p.  31. 


Injury  to  a  Pregnant  Uterus.  461 

In  the  case  recorded  by  Sir  Spencer  Wells,  this 
operator  had  removed  a  large  adherent  multilocular  cyst 
of  the  left  ovary,  when  he  felt  what  was  supposed  to  be  a 
cyst  of  the  right  ovary.  When  tapped,  it  was  found  to 
be  a  gravid  uterus.  The  pregnancy  had  advanced  to 
near  the  fifth  month.  On  discovering  the  mistake, 
Ccesarean  section  was  at  once  performed.  The  patient 
recovered. 

In  Dr.  Byford's  case  pregnancy  had  advanced  to  the 
seventh  month.  The  ovarian  cyst  was  removed  in  the 
usual  manner.  The  trocar  puncture  in  the  uterus  was 
enlarged,  the  foetus  and  placenta  removed,  and  the 
uterine  wound  closed  by  interrupted  silk  sutures.  Before 
the  wound  was  closed,  the  cervical  canal  was  dilated 
with  the  finger.  The  patient — a  single  lady,  aged 
twenty-three  years,  of  unblemished  character — recovered. 

Hillas,*  whilst  operating  on  a  single  woman  twenty- 
four  years  of  age,  wounded  the  gravid  uterus  whilst  open- 
ing the  peritoneum.  On  discovering  the  accident,  he 
removed  the  ovarian  cyst,  emptied  the  uterus,  and  closed 
the  uterine  incisions  with  interrupted  silver  wire  sutures. 
The  patient  recovered. 

Dr.  Fortescue,t  whilst  operating  on  an  unmarried 
girl  twenty-one  years  of  age,  found  w^hat  wTre  supposed 
to  be  two  cysts.  One  was  tapped  and  removed.  On 
thrusting  the  trocar  into  the  second  tumour,  it  turned 
out  to  be  a  pregnant  uterus.  Porro's  operation  was 
performed,  and  the  patient  recovered. 

The  third  method,  of  simply  sewing  up  the  puncture, 
has  been  practised  by  Lee.  J  It  was  a  case  in  which  an 
ovarian  cyst  complicated  pregnancy  in  a  woman  twenty- 

*  Australian  Medical  Jotcrnal,  1875,  p.  33. 

f  Australian    Medical    Gazette,    May,    1884 ;     Med.    Times    and 
Gazette,  Nov.  8th,  1884. 

X  American  Journal  of  Obstetrics,  vol.  xvi.  pp.  286  and  942. 


462  Ovarian  and  Tubal  Diseases. 

eight  years  of  age.  After  the  abdomen  was  opened  and 
the  cyst  exposed,  the  patient  was  turned  on  her  side, 
preparatory  to  puncturing  the  cyst.  This  movement 
displaced  the  cyst :  the  enlarged  uterus  rolled  up  to  the 
incision,  and  was  punctured  with  the  trocar,  instead  of 
the  cyst.  The  wound  in  the  uterus  was  sewn  up  with 
carbolised  silk  sutures.  The  ovarian  cyst  was  removed 
in  the  usual  way,  and  the  abdominal  incision  closed. 
The  patient  recovered,  and  left  the  hospital  five  weeks 
after  the  operation.  Three  days  after  her  return  home 
she  presented  symptoms  of  miscarriage.  The  cervix  was 
dilated,  and  eventually  the  child  was  born.  The  mother 
made  a  perfect  recovery. 

Dr.  Erskine  Mason,*  in  performing  ovariotomy  on  a 
single  woman  thirty  years  of  age,  punctured  a  gravid 
uterus.  He  closed  the  wound  with  sutures.  Abortion 
occurred  next  day.     The  patient  died  in  six  hours. 

Pollockf  removed  an  ovarian  cyst,  and,  mistaking  the 
gravid  uterus  for  another  cyst,  stabbed  it  with  a  trocar. 
Discovering  his  error,  he  closed  the  wound  with  a  silver 
suture.  The  patient  gave  birth  to  a  dead  foetus,  of 
about  the  fifth  month,  a  few  hours  after  the  operation, 
and  died  in  two  hours. 

These  cases  seem  to  show  that  the  best  plan  is  to 
empty  the  uterus,  dilate  the  cervix  from  the  uterine 
cavity,  and  close  the  uterine  incision,  as  after  Csesarean 
section. 

Haemorrliag-e. — Intermediate  hcemorrhage  may  be 
due  to  the  slipping  of  an  ill-applied  ligature,  either  upon 
the  pedicle  or  on  an  adhesion.  The  pedicle  may  bleed, 
not  from  actual  slipping  of  the  ligature,  but  from  its  not 
being  applied  with  sufficient  firmness. 

*  New  York  Pathological  Society,  ^-^77,  and  v4w.  Journal  of  Obstet. 
vol.  xii.  p.  31. 

f  Lancet,  1862,  vol.  ii.  p.  257. 


PERirONITIS.  463 

Adhesions  which  merely  feebly  ooze  when  a  patient 
is  faint  and  collapsed  will  discharge  a  dangerous  quantity 
of  blood  when  reaction  succeeds  shock.  Severe  hemor- 
rhage is  manifested  by  the  well-known  signs  of  internal 
bleeding,  pallor,  cold  skin,  rapid  but  feeble  pulse,  sighing 
respiration. 

When  these  signs  are  manifested,  the  wound  must 
be  reopened,  the  clots  turned  out,  and  the  bleeding  point 
secured. 

Hcemorrhage  usually  occurs  within  the  first  thirty-six 
hours.  After  enucleation  has  been  practised,  and  the 
broad  ligament  ligatured,  but  not  drained,  bleeding  may 
take  place  within  it,  and  form  a  hsematoma  of  the  broad 
ligament.     As  a  rule,  it  is  slowly  absorbed. 

Peritonitis  used  to  be  a  frequent  cause  of  death. 
Its  frequency  has  been  diminished  by  improved  methods 
of  dealing  wdth  the  pedicle,  greater  cleanliness,  antiseptic 
and  aseptic  precautions,  and  the  employment  of  irriga- 
tion, with  or  without  drainage. 

Peritonitis  may  arise  from  infection  of  the  peritoneum 
at  the  time  of  the  operation,  in  consequence  of  the  escape 
of  pus  or  other  fluid  from  the  interior  of  cysts  or  tumours  ; 
from  sponges  and  instruments  inadvertently  left  in  the 
abdomen ;  from  operations  conducted  in  rooms  in  which 
sewer  gas  and  similar  deleterious  agents  are  present ; 
from  damage  to  and  subsequent  sloughing  of  portions  of 
the  viscera,  gangrene  of  the  stump,  pieces  of  adherent 
cyst  wall,  or  adhesions  ;  from  decomposition  of  blood 
carelessly  left  in  the  pelvis,  or  that  has  oozed  after  the 
operation. 

Its  occurrence  in  a  fatal  form  is  not  likely  to  be  mis- 
taken. The  pulse  is  rapid,  120,  130,  or  140,  at  first  full 
and  bounding,  then  quickly  becoming  thin  and  feeble. 
The  temperature  may  be  sub-normal,  then  slowly 
rise  to   100°,  102°,  or  T03^     These   signs,   accompanied 


464  Ovarian  and  Tubal  Diseases. 

by  vomiting,  the  fluid  being  bile-stained  or  like  black 
coffee,  an  anxious  and  pinched  face,  sunken  eyes,  and 
distended  abdomen,  form  a  picture  never  mistaken  when 
once  seen.      Death  is  rarely  long  delayed. 

Foreign  bodies  left  in  the  abdomen. — Every 
writer  on  ovariotomy  insists  on  the  importance  of  exer- 
cising the  utmost  personal  vigilance  in  counting  instru- 
ments^ and  especially  sponges^  after  an  abdominal  operation. 
Nearly  all  the  cases  in  which  foreign  bodies  are  left  in 
the  abdomen  die  unless  they  are  removed,  and  more 
than  one  writer  has  expressed  the  opinion  that  the  acci- 
dent has  probably  been  overlooked  where  no  post  mortem 
was  made.* 

In  several  instances  the  surgeon  has  found  the 
number  of  sponges  or  forceps  short,  and,  failing  to  find 
them  about  the  room,  has  re-opened  the  wound,  and 
recovered  the  missing  instrument  or  sponge. 

Dr.  Holland!  has  reported  briefly  the  details  of  a 
case  in  which  he  removed  two  very  adherent  ovaries. 
Symptoms  of  haemorrhage  set  in,  and  the  wound  was 
reopened.  A  few  hours  later  the  bleeding  recurred, 
necessitating  a  third  opening  up  of  the  wound.  Sub- 
sequently a  sponge  was  reported  to  be  missing,  and 
eventually  the  abdomen  was  opened  again,  but  no  sponge 
was  found.  Thus,  in  twenty-four  hours  this  woman  was 
etherised  and  her  abdomen  opened  on  four  separate 
occasions.     She  recovered. 

Dr.  H.  P.  C.  Wilson,  of  Baltimore,  reported  a  case  in 
which  he  left  a  sponge  in  the  abdomen,  after  removing 
a  large  ovarian  dermoid  from  a  woman  five  months 
pregnant.  Eighteen  days  after  the  operation  the  patient 
miscarried.      An    abscess    afterwards   formed    near   the 


*  Doran :  Gyncecological  Operations. 
t  Brit.   Gyn.  Journal,  vol.  vii.  p.  179. 


Foreign  Bodies  in  the  Abdomen.  465 

umbilicus,  and  five  months  after  the  operation  the  sponge 
was  discharged  piecemeal ;  the  patient  was  subsequently 
restored  to  perfect  health.* 

This  case  induced  him  to  collect  from  surgical  litera- 
ture^ and  from  the  personal  reports  of  friends,  twenty- 
eight  cases  in  which  foreign  bodies  had  beeji  left  in  the 
abdomen. 

In  a  few  cases  a  forceps  was  left  behind,  in  the  rest 
it  was  a  sponge.  This  induced  Dr.  Wilson  to  believe 
that  two-thirds  of  the  cases  never  come  to  light,  partly 
froni  the  anxiety  of  the  surgeon  to  conceal  the  matter, 
and  partly  from  want  of  an  autopsy. 

This  seems  to  be  the  only  case  as  yet  reported  in 
which  a  patient  has  survived  with  a  sponge  left  in  the 
abdomen. 

Olshausenf  mentions  a  case  in  which  a  pressure 
forceps  was  passed  by  the  rectum  nine  months  after 
ovariotomy. 

Nussbaum  tells  of  a  drainage-tube  that  remained 
two  months  in  a  patient's  body,  when  a  part  of  the 
wound  opened  after  a  dance,  and  the  tube  was  at  once 
pulled  out  by  the  patient.  She  suffered  no  further  con- 
sequence. 

Sir  Spencer  Wells  on  one  occasion  left  a  pair  of 
forceps  in  the  abdomen.  The  accident  was  suspected  ; 
some  hours  later  the  abdomen  was  re-opened,  and  the 
missing  forceps  found  in  a  fold  of  omentum.  The  same 
surgeon  reports  that  in  a  patient  on  whom  he  performed 
ovariotomy,  he  removed  a  pair  of  forceps  from  the 
bladder  one  month  afterwards.     The  patient  died.  J 

A  case  is  reported  from  Australia,  g  in  which  a  pair  of 

*  Wilson  :   Trans.  Am.  Obstet.  Soc,  1884,  vol.  ix.  p.  94, 
f  Krankheiten  der  Ovarien,  s.  332,  1886. 
j  Ovarian  Ttimours,  case  917,  p.  336. 
\  Australian  j\led.  Jojtrnal,  1876,  p.  327. 

E  E 


466  OrA  K I A  N  A  ND   Tuba  l  D  /sea  ses. 

bull-dog  forceps  and  a  sponge  were  found  in  the  abdo- 
minal cavity,  after  a  fatal  case  of  ovariotomy.  This  over- 
sight, however,  was  not  the  cause  of  death. 

Sponges  are  left  in  the  abdomen  far  more  frequently 
than  the  published  records  indicate. 

Parotitis. — Inflammation  of  the  parotid  gland  has 
been  many  times  noticed  during  recovery  from  surgical 
procedures,  especially  after  abdominal  operations,  and 
with  exceptional  frequency  during  convalescence  from 
ovariotomy.  The  facts  relating  to  this  matter  have  been 
carefully  formulated  by  Mr.  Stephen  Paget,  in  a  paper 
communicated  to  the  Medical  Society,  London,  in  which 
he  analysed  loi  cases  of  parotitis  ensuing  upon  injury  or 
disease  of  the  abdomen  and  pelvis.  Of  these,  lo  followed 
injury  or  disease  of  the  urinary  tract;  i8  followed  injury 
or  disease  of  the  alimentary  canal ;  23  injury  or  disease 
of  the  abdominal  wall,  sub-peritoneal  or  pelvic  cellular 
tissue ;  and  50  injury,  disease,  or  temporary  derange- 
ment of  the  generative  organs.  Of  the  50  cases  con- 
sequent on  injury,  etc.,  to  the  generative  organs,  27 
followed  ovariotomy  or  oophorectomy. 

The  chief  conclusions  to  which  Mr.  Paget  arrived 
may  be  summarised  thus  :— 

This  form  of  parotitis  has  no  period  of  incubation  ;  it 
may  occur  on  the  first  day  after  the  primary  lesion,  or  be 
delayed  to  the  nineteenth. 

It  is  rarely  attended  by  much  disturbance  of  the 
general  condition  of  the  patient;  in  the  majority  of  cases 
there  is  a  slight  rise  of  temperature,  and  rarely  rigors. 

In  a  large  proportion  of  the  cases  the  gland  sup- 
purates ;  the  affection  runs  no  regular  course  :  it  may  sub- 
side, recur,  and  subside  again.  Although  it  complicates 
pyaemia  and  septicaemia,  it  is  most  frequently  indepen- 
dent of  these  conditions.* 

*  Lancet,  1887,  vol.  i.  p.  ^14, 


Insanity.  467 

Tetanus. — This  dread  complication  of  wounds 
occasionally  occurs  after  ovariotomy.  In  the  experience 
of  British  surgeons  it  is  very  rare,  but  it  appears,  from  the 
statements  of  Olshausen,  to  be  much  more  frequent  on 
the  Continent.* 

Doran  significantly  writes  : — "  This  disease,  rare  as  it 
is  under  the  circumstances,  is  generally  in  itself  sufficient 
to  prevent  a  very  long  series  of  ovariotomies  from  show- 
ing 100  per  cent,  recoveries." 

Iiiisaiiity. — Attacks  of  acute  mania  during  convales- 
cence from,  and  subsequent  to,  ovariotomy,  have  been 
several  times  recorded.  Mr.  Barwell  f  communicated  a 
case  of  this  nature  to  the  Clinical  Society,  London,  under 
the  title.  An  Unusual  Sequel  to  a  Case  of  Ovariotomy^ 
the  sequel  referred  to  being  an  attack  of  mania.  In  the 
paper  he  refers  to  cases  mentioned  to  him  by  Bantock, 
Dent,  Thornton,  and  others.  Since  the  publication  of 
Barwell's  case,  many  others  have  been  recorded,  which 
serve  to  show  that  acute  mania  may  be  regarded  as  one 
of  the  complications  which  follow  this  operation,  even 
after  rigid  exclusion  of  transient  attacks  of  delirium,  due 
to  absorption  of  carbolic  acid  employed  in  the  operation. 

The  attacks  of  mania  in  nearly  all  cases  quickly  sub- 
sided ;  in  a  few  instances  the  patient  has  remained  insane 
for  many  months. 

Vascular  disturbances. — Thrombosis  and  em- 
bolism, with  their  usual  sequences,  occur  after  ovariotomy. 

Thrombosis  is  due  to  the  formation  of  clot  in  the 
veins  of  the  pedicle.  When  ovariotomy  is  performed 
during  pregnancy,  or  oophorectomy  for  myoma,  the 
veins  of  the  pampiniform  plexus  and  the  uterine  veins 
are  usually    exceedingly  large  vessels.      After  ligature, 

*  Krankheiien  der  Ovarien,  p.  369.      This  author  furnishes  a  table 
of  38  cases. 

+  Clin.  Trans.,  London,  vol.  xviii.  p.  199. 

E  E    2 


468  Ol^ARIAN  AND    TUBAL    DISEASES. 

the  blood  in  these  veins  may  thrombose,  and  if  the 
patient  gets  about  too  soon,  the  clotting  may  extend  to 
the  iliac  veins,  and  even  beyond,  giving  rise  to  symptoms 
identical  with  those  seen  in  "  phlegmasia  alba  dolens." 
After  ovariotomy  slight  swelling  of  the  leg  may  occur, 
but  with  continued  rest  in  bed  this  soon  subsides. 

It  is  a  good  plan,  when,  a  patient  has  had  transient 
attacks  of  oedema  of  one  or  both  legs  before  the  opera- 
tion, to  anticipate  complication  in  this  direction  by 
keeping  them  strictly  confined  to  bed  at  least  a  week 
longer  than  the  usual  time.  As  a  rule,  when  such 
patients  begin  to  move  about,  the  oedema  declares  itself, 
unless  they  have  had  a  long  rest  in  bed. 

Embolism. — Thornton  *  mentions  the  case  of  a 
woman  aged  twenty-three  years,  from  whom  he  removed 
both  ovaries  for  cystic  disease.  The  patient  was  doing 
well  up  to  the  eleventh  day.  "  She  woke  in  the  night, 
chatted  and  laughed  with  the  nurse,  and  fell  back  dead." 
No  necropsy  was  allowed. 

Iiitestjiial  eomplicatioiis. — It  has  been  already 
pointed  out  that  ovarian  cysts  may  cause  intestinal 
obstruction,  by  pressing  on  the  rectum  or  sigmoid  flexure, 
by  adhesion  of  the  intestine  to  the  cyst  wall,  or  by  actual 
strangulation  of  the  gut  by  the  pedicle. 

After  removal  of  the  ovaries,  whether  for  cystic  con- 
ditions or  inflammatory  affections,  the  patient  still  runs 
some  risk  of  this  serious,  and,  as  a  rule,  fatal  compli- 
cation. 

It  is  difficult  to  estimate  with  any  approach  to 
accuracy  the  proportionate  amount  of  risk  ;  nevertheless, 
an  examination  of  large  lists  of  consecutive  operations 
on  the  ovaries  and  Fallopian  tubes  will  show  that  the 
danger  is  a  real  one. 

*  Mcd.-Chir,  Trans,,  vol,  Ixx.  p.  55. 


Intestinal  Obstruction.  469 

In  a  case  of  acute  intestinal  obstruction  eight  days 
after  ovariotomy,  Meredith*  re-opened  the  abdomen,  and 
relieved  a  piece  of  intestine  which  had  become  kinked, 
"in  consequence  of  the  traction  exerted  upon  it  by  a 
piece  of  ligated  omentum  which  was  closely  adherent  to 
its  surface."     The  patient  recovered. 

The  obstruction  may  be  acute  or  chronic  :  may  super- 
vene within  a  few  days  of  the  operation  or  be  delayed 
months,  or  even  years.     The  causes  are  various. 

When  intestine  has  been  extensively  adherent  to 
an  ovarian  cyst,  so  that  the  serous  surface  becomes 
destroyed  during  the  separation,  such  a  surface  quickly 
adheres  to  a  neighbouring  piece  of  gut  ;  the  adhesion 
may  lead  to  the  formation  of  a  band,  and  this  may 
strangle  an  adjacent  coil  of  intestine. 

The  pedicle  has  been  the  source  of  danger ;  a  piece 
of  intestine  or  omentum  may  contract  adhesions  to  it, 
and  lead  to  fatal  strangulation. 

Adhesions  of  intestine  and  omentum  to  the  ab- 
dominal cicatrix  are  by  no  means  infrequent,  and  have 
been  known  to  lead  to  fatal  occlusion  even  six  years  after 
ovariotomy.! 

This  frequent  union  of  intestine  to  the  cicatrix  must 
be  borne  in  mind  in  performing  abdominal  section  a 
second  time  on  the  same  patient.  On  more  than  one 
occasion,  ignorance  of  this  fact  has  led  to  injury  of  the 
gut  and  subsequent  faecal  fistula,  with  all  the  distress  it 
causes. 

Obstruction  has  been  caused  by  a  piece  of  intestine 
being  included  in  one  of  the  sutures  applied  to  the  ab- 
dominal wound. i  This  is  an  accident  always  to  be 
guarded  against  in  suturing  the  incision.     Intestine  has 

*  Lancet,  April  3rd,  1886,  p.  641. 

f  Shively  :  New  York  Med.  Journal,  vol.  xl.  p.  292. 

X  Doran  :   GyncBcological  Operations ,  p.  264. 


47°  Ol'ARIAN  AND    TUBAL    DISEASES. 

been  included  in  the  clamp,  or  compressed  between  the 
clamped  pedicle  and  the  abdominal  wall.  Hegar  mentions 
a  case  in  which  an  epiploic  appendix  was  included  in  the 
ligature,  and  caused  acute  and  fatal  flexion  of  the  intestine. 

Perforation. — This  accident  may  occur  as  a  result  of 
acute  intestinal  obstruction  following  ovariotomy.  It  may 
be  occasioned  by  the  end  of  a  drainage-tube  resting  upon 
a  piece  of  gut  instead  of  the  bottom  of  the  recto-vaginal 
pouch.  The  prolonged  pressure  of  the  tube  would  lead 
to  sloughing  of  the  wall  of  the  bowel.  Should  an  abscess 
form  around  the  pedicle,  this  may  lead  to  adhesion  and 
implication  of  an  adjacent  coil  of  bowel,  and  faecal 
extravasation  into  the  abscess.  In  fortunate  cases  this 
abscess  will  find  a  vent  through  the  abdominal  wound, 
and  a  temporary  fsecal  fistula  will  be  the  consequence. 
With  the  present  excellent  method  of  treating  the  pedicle, 
such  complications  are  excessively  rare.  They  occa- 
sionally occur  as  sequelae  to  operations  for  advanced 
tubal  pregnancy. 

The  risk  of  a  faecal  fistula  must  be  counted  among 
the  disadvantages  attending  the  use  of  the  drainage-tube. 

Sir  Spencer  Wells*  has  given  some  cases  in  detail 
illustrating  intestinal  obstruction  and  faecal  fistula  fol- 
lowing ovariotomy  which  well  repay  perusal. 

Ulceration  of  the  intestine  is  a  very  unusual 
cause  of  death  after  ovariotomy. 

Reference  has  already  been  made  to  an  interesting 
case,  reported  by  Doran,  in  which  a  woman  twenty-six 
years  of  age  died  after  the  removal  of  an  ovarian  tumour. 
At  the  post  f?iorte?n  examination  a  perforating  ulcer  was 
found  in  the  ileum.  The  pathological  and  clinical  import 
of  this  case  is  discussed  on  page  131. 

I  have  once  had  an  opportunity  of  investigating  a 

*  Ovariayi  and  Uterine  Tumours,  p.  425  ;    1882. 


Repeated  Ovariotomy.  471 

case  which  occurred  in  the  practice  of  a  colleague  in 
which  a  woman  died  after  the  removal  of  a  small  ovarian 
dermoid.  The  patient  was  thirty-three  years  of  age,  and 
three  months  pregnant  with  her  sixth  child.  The  opera- 
tion was  a  simple  one,  and  as  the  left  ovary  was  cystic, 
it  was  also  removed.  Her  symptoms  after  the  operation 
were  somewhat  anomalous,  and  she  died  on  the  eighth 
day.  At  the  post  morteiii  examination  several  ulcers  were 
found  in  the  jejunum,  one  of  which,  situated  six  feet  from 
the  duodenum,  had  perforated,  and  caused  fatal  peritonitis. 
There  had  been  no  symptoms  of  obstruction  at  any  time, 
or  any  evidence  to  lead  to  the  supposition  that  there  was 
disease  of  the  intestine. 

Repeatecl  ovariotomy. — -In  a  large  number  of 
cases  patients  have  been  twice  submitted  to  ovariotomy. 
A  knowledge  of  this  fact  always  induces  the  surgeon,  when 
performing  ovariotomy,  to  examine  carefully  both  ovaries, 
and  when  there  is  evidence  of  disease,  to  remove  both 
glands.  The  second  ovary  must  not  be  removed  unless 
the  surgeon  feels  very  strongly  that  it  is  likely  to  give  the 
patient  trouble,  for  in  very  many  cases  women  have  be- 
come mothers  after  ovariotomy,  and  given  birth  to  twins, 
and  even  triplets.  This  fact  is  sufficient  to  prohibit  the 
removal  of  both  ovaries  as  a  constant  practice  in 
ovariotomy. 

The  records  do  not  show  that  a  second  ovariotomy  is 
attended  with  more  than  the  usual  risk  of  a  first  ovariotomy. 
It  is  necessary  to  remember  that  the  abdominal  incision 
must  be  cautiously  made,  because  in  very  many  in- 
stances intestine  may  be  adherent  to  the  cicatrix,  and 
under  conditions  rendering  it  very  liable  to  be  wounded. 
It  must  also  be  remembered  that  the  cicatrix  is  often 
very  thin,  and  the  knife  entering  the  peritoneal  cavity 
suddenly  may  do  much  mischief  before  the  surgeon  is 
aware  of  it. 


472  Ovarian  and  Tubal  Diseases. 

It  is  recommended  by  some  writers  that  in  a  second 
ovariotomy  the  opening  may,  with  advantage,  be  made  a 
little  to  one  side  of  the  original  incision. 

Cases  have  been  reported  in  which  patients  have  been 
three  times  submitted  to  ovariotomy  ;  it  is,  of  course,  im- 
possible that  an  ovarian  cyst  was  removed  on  each 
occasion.  That  tumours  were  removed  there  can  be  no 
doubt,  but  it  does  not  necessarily  follow  that  they  all 
originated  in  the  ovary.  The  idea  that  the  patient 
possessed  three  ovaries,  each  of  which  became  cystic,  is 
pure  assumption.* 

Tlie  fate  of  the  ligature.— When  a  ligature  is 
satisfactorily  applied  to  a  pedicle,  it  is  clear  that  the 
tissue  on  the  distal  side  of  the  ligature  is  isolated  from 
the  circulation.  The  fate  of  this  tissue,  and  of  the  liga- 
ture, has  been  made  the  subject  of  much  speculation. 

It  is  a  matter  of  common  observation  that  when 
animal  tissues  are  cut  off  from  the  circulation,  they 
atrophy  and  shrivel.  When  micro-organisms  gain  access 
to  such  parts,  fermentation  and  decomposition  ensue. 
In  due  course,  through  the  activity  of  leucocytes,  the 
dead  tissues  are  detached  from  the  living — ^a  process 
termed  in  surgery  sloughing. 

When  a  piece  of  tissue  is  removed  from  a  living  body, 
and  immersed  in  a  sterilised  solution,  and  absolutely 
isolated  from  the  atmosphere,  decomposition  will  be  post- 
poned in  it  for  an  indefinite  time,  but  as  soon  as  un- 
sterilised  air  is  allowed  access  to  it,  putrefaction  at  once 
ensues. 

The  pedicle,  after  an  ordinary  ovariotomy,  is  in  an  air- 
tight cavity  ;  the  tissues  included  in  the  ligature  are 
healthy,  hence,  when  such  a  pedicle  is  returned  to  the 
abdomen,  it  resembles  the  piece  of  tissue  removed  from 
contact  with  the  atmosphere.     No  fermentative  changes 

*  Buchanan  :  Brit.  Med.  Journal,  1891,  vol.  ii.  p.  118,  and  p.  336. 


The  Fate  of  the  Ligature.  473 

occur,  but  aggressive  leucocytes  attack  and  gradually  di- 
gest the  ligature,  and  in  course  of  time  effect  its  removal. 

In  order  that  a  piece  of  silk,  gut,  tendon,  or  whip-cord 
applied  to  a  pedicle  shall  be  retained  until  digested,  two 
conditions  must  be  fulfilled  :  the  ligatured  tissue  must  be 
healthy,  and  air  must  be  excluded. 

It  has  been  established  that  after  simple  ovariotomy 
the  pedicle  rarely  sloughs,  but  it  is  quite  certain  that  when 
ovaries  and  Fallopian  tubes  are  removed  for  inflammatory 
diseases,  such  as  pyosalpinx,  the  pedicle  is  often  a  source 
of  disaster.  In  many  operations  in  which  drainage  is 
resorted  to,  the  pedicle  is  apt  to  slough  and  give  rise  to  a 
sinus,  through  which  the  ligature  is  ultimately  discharged. 

Many  surgeons  refuse  to  believe  that  the  ligature 
causes  trouble ;  this  is  idle.  In  several  instances  it  has 
formed  the  nucleus  of  a  vesical  calculus ;  it  has  been  dis- 
charged through  the  rectum,  and  in  many  patients  it 
has,  months  after  the  operation,  escaped  through  a  sinus 
in  the  parietal  cicatrix.  When  the  pedicle  sloughs  soon 
after  the  operation,  and  before  adhesions  isolate  it  from 
the  general  peritoneal  cavity,  it  may  cause  fatal  peri- 
tonitis. 

Two  things  cause  trouble  in  the  pedicle  ;  the  struc- 
tures composing  it  are  the  Fallopian  tube,  ovarian  liga- 
ment, and  blood-vessels  included  between  the  layers  of 
the  peritoneum  forming  the  mesosalpinx.  When  that 
portion  of  the  tube  included  in  the  ligature  is  the  seat  of 
septic  changes,  it  must  necessarily  endanger  the  safety  of 
the  pedicle,  and  cause  it  to  slough,  or  set  up  inflam- 
matory changes  around  the  ligature,  which  not  infre- 
quently nullify  the  good  effects  of  the  operation. 

It  must  also  be  pointed  out  that  one  of  the  disadvan- 
tages of  drainage  is  that  it  admits  air  into  the  peritoneal 
cavity,  so  that  if  a  pedicle  contain  septic  elements,  the 
admission  of  air  will  serve  to   establish  decomposition, 


474  Ovarian  AND  Tubal  Diseases. 

and  in  a  certain  proportion  of  cases  induce  separation 
of  the  ligature. 

An  inquiry  into  this  question  shows  that  after  simple 
ovariotomy  or  oophorectomy  for  myomata,  a  properly 
tied  pedicle  rarely  causes  trouble,  but  when  oophorectomy 
is  performed  for  the  condition  known  as  pyosalpinx,  the 
ligature  is  a  source  of  irritation,  and  in  a  fair  proportion  of 
cases  causes  abscess  ;  this  is  more  likely  to  happen  when 
drainage  has  been  necessary.  The  local  suppuration  may 
lead  to  general  peritonitis,  or  the  pus  may  escape  through 
the  rectum,  bladder,  or  abdominal  wall. 

AtosorptioEi  of  tlie  lig-atiia'e,  when  silk  is  used, 
takes  place  slowly.  In  one  patient,  whose  abdomen  was 
reopened  one  year  after  double  oophorectomy,  I  found 
the  knots  only  of  the  silk  used  for  the  pedicles.  In 
another  instance  in  which  I  performed  hysterectomy, 
three  years  after  double  oophorectomy,  no  traces  of  five 
silk  ligatures  applied  in  the  original  operation  were  de- 
tected, after  a  most  rigorous  search. 

Historical. 

1809.  Ephraim  McDowell,  Kentucky,  performed  the  first  ovariotomy. 
He  tied  the  pedicle,  but  left  the  ligature  hanging  out  of 
the  wound.  (The  patient  survived  the  operation  32  years. 
— Lawson  Tait.) 
1 82 1.  Nathan  Smith,  New  England,  tied  the  vessels  in  the  pedicle 
w^ith  strips  of  a  kid-glove,  and  returned  it  into  the 
abdomen. 
1850.   Hutchinson  introduced  the  clamp. 

1S64.   Baker    Brown  introduced   the   cautery.     Lawson    Tait   also 
gives  this  surgeon  the  credit  of  re-introducing  and  estab- 
lishing the  intra-peritoneal   method   of  dealing  with    the 
•pedicle   which   has  led  to  such  brilliant   results.      Doran 
ascribes  it  to  the  systematic  advocacy  of  Dr.  Tyler  Smith. 
Those  interested  in  this  subject  should  read  Doran's  paper  in 
The  St.  Barth.  Hosp.  Reports,  1877,  vol.  xiii.  p.  195, 

Lawson  Tait,  Diseases  of  the  Ovaries,  1883,  pp.  238  and  286. 
Dr.  Stansbury  Sutton,  Trans.  Am.  Gyn.  Soc,  vol.  vii.  p.  119. 


475 


CHAPTER    XLII. 

THE    EFFECTS    OF    THE    REMOVAL    OF    THE    OVARIES     ON 
THE    SECONDARY    SEXUAL    CHARACTERS    OF    WOMEN.* 

In  the  opening  chapter  of  this  book  the  primary  and 
secondary  sexual  characters  of  the  human  family  were 
briefly  considered.  The  behaviour  of  these  characters 
after  removal  of  the  genital  glands  in  women  has  not 
been  dealt  with  in  an  impartial  way,  and  the  consequence 
is  that  few  opinions  in  the  profession  of  medicine  rest 
upon  such  unsatisfactory  evidence  as  those  relating  to  the 
effects  of  double  ovariotomy,  or  oophorectomy,  on  the 
secondary  sexual  characters.  It  is  imagined  by  many 
that  after  removal  of  the  ovaries  women  become  hairy 
about  the  face,  the  m.amm^  atrophy,  and  they,  in  short, 
assume  many  of  the  secondary  sexual  characters  of  the 
male. 

This  error  may  be  traced  to  two  sources.  One  is  the 
assumption  that  certain  changes  observed  in  birds  and 
deer  after  injury  to,  or  disease  of,  the  sexual  glands  holds 
good  in  men  and  women ;  the  other  source  of  error  is 
the  oft-quoted  case  reported  by  Percival  Pott.f  In  this 
case  a  robust  and  healthy  woman,  twenty-three  years  of  age, 
suffered  so  much  inconvenience  from  a  swelling  in  each 
groin,  that  after  due  consideration  they  were  removed. 
The  bodies  excised  from  these  swellings  were  regarded  as 
ovaries,  but  they  were  not  examined  microscopically. 
The  concluding  paragraph  of  Pott's  brief  account  of  the 

*  hiternational  Clifiics,  vol.  ii.  p.  2i6';   1891. 
t  Chirur^ical  Works,  case  xxiv.  p.  791  ;    1775. 


476  Ovarian  AND  Tubal  Diseases. 

case  is  this  : — "  She  has  enjoyed  good  health  ever  since, 
but  is  become  thinner  and  more  apparently  muscular; 
her  breasts,  which  were  large,  are  gone  ;  nor  has  she  ever 
menstruated  since  the  operation,  which  is  now^  some  years." 

This  is  a  typical  example  of  the  flimsy  evidence  on 
which  text-book  writers  rely.  In  this  case  there  are  only 
two  facts  stated  with  any  approach  to  certainty  :  these  are 
(i)  the  woman  ceased  to  menstruate  ;  (2)  years  afterwards 
her  breasts  were  gone.  It  must  be  remembered  we  have 
no  proof  that  the  bodies  removed  from  the  groins  w^ere 
ovaries.  In  some  instances  when  organs  supposed  to  be 
ovaries  have  been  removed  from  the  inguinal  canals,  the 
microscope  has  shown  them  to  be  testes.  Dr.  Chambers's 
well-known  case  is  an  instance  of  this,  and  I  have  seen  two 
others.  The  only  evidence  in  Pott's  case  that  the  bodies 
were  ovaries  is  the  statement  that  she  menstruated  regu- 
larly before  the  operation.  I  know  of  no  case  in  w^hich 
menstruation  co-existed  with  testes,  but  well-developed 
mammae  may  be  associated  with  testes,  as  in  Chambers's 
celebrated  case  {see  page  25) ;  and  it  is  a  curious  fact 
that  in  this  instance  it  is  reported  a  month  after  the 
operation  :  "  The  left  breast  has  almost  disappeared, 
w^hile  the  right  remains  the  same  as  before  the  operation." 
Pott's  case  no  more  proves  that  the  removal  of  the  ovaries 
will  lead  to  the  atrophy  of  the  mammae  and  the  assump- 
tion of  secondary  sexual  characters  than  that  the  exist- 
ence of  antlers  in  a  doe  roe-deer  indicates  sterility.  As 
antlered  does  are  instructive  in  relation  to  this  question, 
it  will  be  useful  to  very  briefly  mention  a  few  facts  in 
this  direction. 

Female  deer  are  occasionally  seen  with  antlers,  which 
resemble  very  closely  the  stunted  specimens  seen  on  the 
heads  of  castrated  bucks.  It  is  believed  by  many  that 
such  specimens  are  very  frequent,  but  an  inquiry  into  the 
matter  shows  that  this  is  not  the  case.     That  female  deer 


Remote  Effects  of  Ovariotojmy.  477 

put  up  antlers  occasionally  is  beyond  doubt.  One  of  the 
most  accessible  specimens  is  preserved  in  the  museum  of 
the  Royal  College  of  Surgeons,  London.  It  is  the  skull 
of  a  doe  roe-deer ;  it  was  shot  by  the  Earl  of  Egremont, 
near  Pet  worth,  Surrey,  in  18 10,  and  presented  by  him  to 
the  museum.  The  antlers,  to  judge  from  the  specimen, 
were  covered  with  "  velvet."  One  is  a  simple  curved 
snag  nearly  eight  cm.  in  length,  with  a  well-developed 
burr  :  .the  other  is  a  mushroom-shaj)ed  burr  without 
any  beam.  Lord  Egremont,  in  a  letter,  expressly  stated 
that  the  deer  was  a  very  old  afid  uncommonly  large  female^ 
with  two  young  ones  in  her.  The  pregnant  condition  of 
this  animal  must  not  be  regarded  as  very  unusual.  In 
Germany,  where  roe-deer  are  more  plentiful  than  in  Great 
Britain,  many  does  with  antlers  have  been  seen  ;  Dr. 
Altum  has  observed  no  fewer  than  forty  instances.  Most 
of  these  were  barren  animals,  and  the  antlers  were  always 
of  a  more  or  less  abortive  character,  except  one  case,  in 
which  the  normal  male  form  was  well  reproduced ; 
several  luere  fertile^  and  were  either  with  }-oung  when 
killed  or  had  recently  given  birth  to  fawns.  Such  ab- 
normal antlers  appear  to  be  persistent,  and  permanently 
covered  with  velvet. 

It  has  been  difficult  to  obtain  precise  information  as 
to  the  actual  condition  of  the  reproductive  organs  in  these 
antlered  females,  and  the  statement  that  they  were  mostly 
barren,-  though  significant,  is  not  sufficiently  precise  for 
our  purpose.  In  1791  Hoy  briefly  communicated  to  the 
Linnean  Society  a  few  facts  about  a  one-horned  hind.  It 
was  a  hind,  the  female  of  Cerviis  elephas,  shot  by  the  Duke 
of  Gordon,  "  which  had  one  horn  perfectly  similar  to  that 
of  a  stag  three  years  old.  It  never  had  a  horn  on  the 
other  side  of  the  head,  for  there  the  corresponding  place 
was  covered  over  by  the  skin,  and  quite  smooth.  It  does 
not   seem   to   have   ever   produced  a  fawn,  and   upon 


47^ 


Ol^'ARIAN   AND    TUBAL    DISEASES. 


dissection,  the  ovarium  of  the  same  side  with  the  horn  icas 
found  to  be  scirrhous y  ^  We  have  authentic  evidence  of 
the  occurrence  of  antlers  in  female  deer  in  the  following 


Fig.  iig. — Head  of  a  Doe  {Capreolus  caprtra)  with  Antlers. 
It  is  beset  with  exostoses,  and  is  velvet-covered. 

species:  Roe-deer  (Fig.  119),  Virginian  deer,  Moose, 
and  Red-deer ;  antlered  females  in  other  Cervidoe  seem 
to  be  of  very  rare  occurrence. 

Thus  the  evidence  shows  that  the  presence  of  antlers 
on  a  doe  is  no  proof  of  sterility  any  more  than  a  slight 
growth  of  hair  on  the  lips  and  chin  of  a  woman  indicates 
barrenness,    for  most  of  us  could  adduce    instances  of 

*■  Transactions,  vol.  ii.  p.  356. 


Effects  of  Oophorectomy.  479 

women  tlie  unfortunate  possessors  of  a  growth  of  hair  on 
the  hp,  but  mothers  nevertheless. 

I  have  made  many  personal  inquiries  into  this  matter, 
and  sought  far  and  wide  in  special  writings  for  evidence 
in  support  of  the  statement  that  removal  of  the  ovaries 
tends  to  cause  abnormal  growth  of  hair.  The  following 
are  characteristic  examples  of  the  evidence  : — Olshausen* 
refers  to  a  case  mentioned  by  W.  Atlee  in  which  a  woman, 
after  excision  of  both  ovaries,  developed  a  beard  fourteen 
years  after  the  operation.  The  patient  was  then  fifty  years 
of  age.  Peaslee  mentions  three  cases  in  which  women 
with  ovarian  trouble  had  tolerable  beards.  He  did  not 
follow  up  the  cases. 

Statements  of  this  kind  must  not  be  accepted  as  evi- 
dence that  the  appearance  of  the  beard  depended  on  the 
removal  of  the  ovaries.  Indeed,  evidence  can  be  quoted 
in  the  -opposite  direction.  Clement  Lucas f  communi- 
cated to  the  Clinical  Society,  London,  a  case  of  early 
puberty  in  a  girl  seven  years  of  age,  from  whom  he  re- 
moved an  ovarian  tumour.  The  external  genitals  were 
precociously  developed,  there  was  considerable  growth  of 
hair  on  the  pubes,  enlarged  mammas,  and  menstruation. 
After  the  operation,  these  signs  for  the  most  part  reverted 
to  their  normal  state  :  before  she  left  the  hospital  the 
prominence  of  the  mamm^  had  much  subsided.  In 
contrast  to  this,  Olshausen  reports  that  he  removed  a 
large  proliferating  ovarian  cyst  from  a  girl  of  sixteen  years 
who  had  not  menstruated.  In  bodily  conformation  she 
resembled  a  girl  of  ten  or  tw^elve  years. 

Mr.  Thornton  and  Dr.  Myrtle  J  have  recorded  the 
details  of  a  very  unusual  case,  in  which  abdominal 
nephrectomy  was  performed  for  a  large  sarcoma  of  the 

*  Die  Krankheiten  der  Ova?-ien,  p.  379;  1886. 
+   Trans.  Clin.  Society,  vol.  xxi.  p.  224. 
X   Trans.  Clin.  Society,  vol.  xxiii.  p.  150. 


480  Ovarian  and  Tubal  Diseases. 

left  supra-renal  capsule  by  Mr.  Thornton.  He  writes  : — 
"  The  patient,  who  was  a  married  lady  of  thirty-six, 
mother  of  one  child,  aged  thirteen,  had  another  curious 
pathological  condition,  which  had  developed  soon  after 
the  oophorectomy  performed  by  Dr.  Keith  six  or  seven 
years  before  I  saw  her.  She  was  covered  all  over  with 
long  silky  black  hair,  and  had  to  shave  her  face  just  like  a 
hairy  man."  Dr.  Myrtle  writes  : — "  Here  I  may  remark 
that  the  mammge  had  disappeared,  and  that  her  cheeks, 
upper  lip,  and  chin  were  covered  with  soft  darkish  down, 
such  as  you  see  on  a  lad  of  eighteen  or  nineteen,  and  that 
the  arms  and  fore-arms  were  also  hairy. ' 

We  must  not  hasten  to  attribute  these  changes  to  the 
removal  of  the  ovaries. 

The  supposed  sarcoma  of  the  supra-renal  capsule  was 
removed  in  April,  1889  ;  in  November  of  the  same  year 
she  wrote  to  Dr.  Myrtle :  "I  am  much  like  my  old  self, 
and  have  all  the  external  appearances  of  other  women." 

The  facts  of  this  case  indicate  that  the  irritation  of 
the  sarcoma  had  more  to  do  with  the  growth  of  hair  than 
the  oophorectomy. 

Let  me  now  consider  the  effects  of  complete  removal 
of  both  ovaries  upon  menstruation.  This  is  an  important 
subject,  because  surgeons  occasionally  remove  both 
ovaries  for  the  purpose  of  anticipating  the  menopause  in 
some  cases  of  uterine  myomata. 

In  1859,  Farre,*  in  his  classical  article  Uterus^  ex- 
pressed the  following  opinion  relative  to  the  influence  of 
the  ovaries  on  menstruation: — ^" Their  artificial  removal  is 
followed  by  a  permanent  cessation  of  the  catamenial  flow, 
although  the  uterus  may  be  left  uninjured."  A  critical 
analysis  of  the  evidence  adduced  by  subsequent  writers 
in  opposition  to  this  opinion  has  served  to  convince  me 

*  Todd's  Cyclopcsdia  ;  Supplement, 


Menstruation  without  Ovaries.  481 

that  Farre  was  absolutely  correct.  It  is  beyond  all  dis- 
pute that  some  women,  after  both  ovaries  and  tubes  have 
been  completely  removed,  suffer  from  discharges  of  blood 
from  the  vagina ;  but  vaginal  haemorrhage  of  any  kind 
does  not  constitute  menstruation. 

Before  discussing  these  irregular  haemorrhages,  it  must 
be  mentioned  that  the  Fallopian  tubes  exercise  no  in- 
fluence on  menstruation,  and  in  order  to  produce  artificial 
amenorrhcea  both  ovaries  must  be  completely  removed. 
Let  me  mention  a  few  facts  that  will  show  that  the  tubes 
exercise  no  influence. 

The  museum  of  the  Royal  College  of  Surgeons  con- 
tains two  large  specimens,  described  in  the  catalogue  as 
dilated  Fallopian  tubes.*  On  one  of  them  there  is  a 
fragment  of  ovary  ;  no  trace  of  the  ovary  can  be  detected 
on  the  other.  Sir  Spencer  Wells,  who  removed  them 
from  a  woman  twenty-three  years  of  age,  reports 
"  that  menstruation  has  continued  regularly  since  the 
operation." 

In  1890  I  attempted  to  perform  double  oophorectomy 
in  a  woman  with  a  large  and  rapidly-growing  uterine 
myoma.  The  right  ovary  and  tube  were  easily  removed. 
The  left  ovary  could  not  be  found,  but  the  left  tube  was 
clearly  and  completely  removed  :  the  woman  menstruates 
as  regularly  as  before  the  operation.  In  December, 
1890,  I  attempted  to  remove  the  ovaries  and  tubes  in  a 
case  of  very  large  myoma.  The  right  were  removed 
easily,  but  the  left  tube  and  ovary  were  so  embedded 
in  the  tumour  as  to  make  their  removal  impossible. 
I  ligatured  the  tube  firmly  with  two  stout  gut  liga- 
tures. The  patient  has  not  missed  a  period  since  the 
operation. 

In  1890  Dr.  Champneysf  performed  Caesarean  section 

*  I  believe  them  to  be  really  dilated  horns  of  a  bi-cornuate  uterus, 
f   Trans.  Obstet,  Soc. ,  vol.  xxxi.  p.  136. 

F  F 


482  Ovarian  AND  Tubal  Diseases. 

on  a  dwarf,  and  in  order  to  prevent  fecundation  he  inge- 
niously ligatured  each  tube  with  a  piece  of  kangaroo 
tendon.  Dr.  Champneys  in  a  letter  informs  me  that  the 
woman  has  menstruated  regularly  since  the  operation. 

We  have  now  to  discuss  the  cases  in  w^hich  so-called 
menstruation  continues  after  removal  of  both  ovaries 
and  tubes.  In  a  few  of  the  reported  cases  menstruation 
appears  for  one,  two,  or  three  periods,  then  ceases  for 
ever.  In  others,  the  patients  have  amenorrhoea  for  a 
few  months,  then  menstruate  for  a  few  periods  before  the 
flow  permanently  ceases. 

In  many  cases  of  double  ovariotomy  or  oophorectomy 
blood  issues  from  the  vagina  within  forty-eight  hours  of 
the  operation,  and  sometimes  lasts  two  days. 

These  irregularities  cannot  be  advanced  seriously  as 
persistence  of  menstruation  after  removal  of  ovaries  or 
tubes.  The  same  irregularity  is  reported  by  women  at 
the  climacteric  period. 

The  cases  we  have  seriously  to  discuss  are  those  in 
which  after  removal,  or  supposed  removal,  of  both 
ovaries  menstruation  has  persisted. 

Mr.  Thornton*  attempts  to  explain  this  by  assuming 
the  existence  of  a  third  ovary.  This  explanation  must 
not  be  entertained.  Ihere  is  no  authe?itic  insta?ice  on 
recoi^d  of  a  third  ovary.  Specimens  reported  as  super- 
numerary ovaries  are  usually  instances  of  deeply-fissured 
ovaries.  Several  cases  of  supposed  third  ovaries  lack 
histological  demonstration,  without  which  they  cannot 
be  received  as  evidence.  This  question  was  discussed 
in  chapter  iii. 

It  is  an  important  fact  that  the  reported  cases  of 
persistent  menstruation  after  removal  of  both  ovaries 
have  usually  been  patients   in  which  the  operation  has 

*  Heath's  Dictionary  of  Surgoy :  article  ' '  Oophorectomy. " 


Menstruation  without  Ovaries.  483 

been   performed  for   chronic  inflammatory  affections  of 
the  tubes  and  ovaries,  or  for  uterine  myoma. 

The  supposed  persistence  of  menstruation  after 
removal  of  both  ovaries  is  capable  of  explanation  in 
two  directions  : — 

1.  In  some  cases  it   is  due  to  imperfect  removal  of 

the  ovaries.  They  may  be  so  adherent  to  sur- 
rounding parts  that  it  is  impossible  to  be  quite 
sure  no  ovarian  tissue  is  left. 
In  uterine  myoma  the  ovary  is  sometimes  elon- 
gated like  a  cord,  and  a  portion  of  the  gland 
may  easily  be  left  on  the  proximal  side  of 
the  ligature,  without  the  surgeon  being  aware 
of  it. 

2.  The  persistent  haemorrhage  in  patients  from  whom 

both  ovaries  have  been  completely  removed  in 
order  to  check  profuse  bleeding,  due  to  myoma, 
is  not  infrequently  caused  by  the  presence  of 
a  submucous  tumour  that  has  been  over- 
looked. 

In  several  such  cases  it  has  been  necessary  to  dilate 
the  uterus  when  the  presence  of  such  a  tumour  has  been 
suspected.  Its  removal  at  once  checks  the  supposed 
menstruation.  Operators  are  rarely  frank  enough  to 
record  such  cases. 

Irregular  haemorrhage  from  the  vagina  simulating 
menstruation  after  complete  oophorectomy  is  in  some 
cases    due   to    the  irritation    of   the  ligatures   used    for 

the  pedicle.       This    subject    requires    extended    investi- 
gation. 

Dr.  Howard  A.  Kelly*  in  a  short  paper  on  The  more 
remote  results  of  removing  the  ovaries  and  tubes,  writes  that 

*   The  John  Hopkins  Hospital  Btilletin,  Baltimore,  May  ist,  1890, 
P-  57- 

FF    2 


484  Ovarian  and   Tun  at.  Drs  eases. 

he  has  "  several  times  seen  severe  hceinorrhages  a  year  or 
two  after  operation."  In  1888  he  removed  two  tubo- 
ovarian  abscesses ;  the  patient  had  a  slow  convalescence, 
but  finally  recovered  complete  health.  Subsequently  she 
suffered  from  periodical  uterine  haemorrhage.  Dr.  Kelly 
discovered  a  mass  about  an  inch  and  a  half  in  diameter  at 
the  right  uterine  cornu,  which  he  regarded  as  an  old 
ligature  encapsuled.  He  performed  abdominal  section, 
removed  a  serous  cyst  apparently  within  the  folds  of  the 
broad  ligament,  and  in  it  found  the  silk  ligature.  There 
was  no  trace  of  ovary  on  either  side. 

He  said  he  could  recall  five  such  cases.  It  must 
also  be  borne  in  mind  that  the  patients  ignorantly  mis- 
take the  source  of  haemorrhage.  On  one  occasion  I 
removed  both  ovaries  and  tubes  for  early  tubal  gestation. 
The  patient  assured  me  that  she  menstruated  as  regularly 
as  before  the  operation ;  for  nearly  two  years  I  believed 
her.  It  then  occurred  to  me  to  verify  the  patient's  state- 
ment. To  my  surprise,  I  found  the  source  of  the 
supposed  menstruation  to  be  internal  piles.  These  I 
removed  :  a  jiroceeding  which  immediately  stopped  the 
haemorrhage. 

In  a  discussion*  on  persistent  menstruation  after 
double  ovariotomy  at  the  Obstetrical  Society  of  New 
York,  October  19,  1886,  Dr.  Afunde  "recalled  an 
oophorectomy  which  he  had  seen  Dr.  Noeggerath 
perform.  The  operation  was  done  for  the  relief  of 
dysmenorrhoea.  The  patient  continued  to  menstruate 
for  a  year  after  her  recovery,  and  the  dysmenorrhoea 
and  other  abdominal  pains  persisted.  Her  abdomen 
was  reopened,  the  intestines,  which  were  found  adherent 
to  the  cicatrix,  were  lifted  out  of  the  pelvis,  the  stumps  of 
the    removed  ovaries   and   the    surrounding    adhesions 

*  Am.  Journal  of  Obstet.,  vol.  xix.  p.  1263. 


Flushing.  485 

were  cut  off  and  then  thoroughly  cauterised ;  yet  after 
this  second  laparotomy  the  patient  continued  to  men- 
struate just,  the  same  as  before.  Four  years  later  she 
entered  the  President's  [Dr.  Munde's]  service  at  Mount 
Sinai  Hospital,  this  time  with  a  well-uiarked  7iterine 
fibf-oid.,  which  he  was  sure  had  not  existed  at  the  last 
operation.  Her  periods  still  recurred  regularly."  She 
refused  further  interference,  and  was  lost  sight  of, 

Vaso-iiiotoi'  €listiirl>aiices. — The  most  frequent 
and  troublesome  form  of  nerve-disturbance  that  is  liable 
to  arise  after  removal  of  both  ovaries  and  tubes  is  the 
peculiar  phenomenon  commonly  termed  "  the  flushes." 

Campbell,*  in  his  interesting  work,  defines  a  flush  as 
a  7ierve-sto7']]i^  i7i  ivhich  a  rush  of  blood  to  the  skin  and 
a  sense  of  heat  are  generally  the  most  obtrusive  manifes- 
tatio7is. 

He  then  goes  on  to  state  that  in  a  fully-developed 
flush  the  patient  at  first  feels  hot,  some  portion  of  the 
skin  being  flushed  with  blood ;  immediately  after,  or 
in  a  very  short  time,  sw^eating  occurs ;  finally,  while  the 
sweat  is  still  on,  or  while  it  is  diminishing,  or  after  it 
has  actually  disappeared,  the  patient  feels  cold  or  may 
shiver. 

It  is  not  my  intention  to  enter  into  the  physiological 
side  of  the  question  ;  those  who  desire  to  do  so  should 
carefully  study  Campbell's  book.  My  intention  is 
merely  to  consider  "  flushing "  as  a  sequel  to  the  re- 
moval of  the  ovaries.  It  is  well-known  that  as  women 
approach  the  menopause  they  are  especially  liable  to 
"heats"  or  "flushes."  When  menstruation  finally 
ceases,  flushes  may  recur  so  frequently  as  to  cause  the 
patient  much  distress. 

In  the   course    of  two   years    they    so    diminish   in 

*  Flushing  and  Moj'bid  Blushing,  London,  1890. 


486  Ol^ARIAN  AND    TuBAL    DISEASES. 

frequency  and  force  that  the  individual  is  no  longer  dis- 
tressed by  them. 

When  the  menopause  is  suddenly  brought  about  by 
the  removal  of  the  ovaries,  these  flushes  begin  to 
manifest  themselves,  and  in  some  patients  they  are 
very  distressing.  I  have  made  many  observations  on 
such  cases,  and  find  it  impossible  to  foretell  before  the 
operation  whether  a  given  patient  will  suffer  from  flushes 
or  not. 

I  find  that  the  phenomenon  ensues  upon  the  opera- 
tion quicker  in  women  who  are  near  the  menopause ; 
it  lasts  longer,  is  more  frequent  and  pronounced  in  them 
than  in  younger  women.  It  seems  to  follow  equally  after 
double  ovariotomy,  oophorectomy  for  inflammatory 
conditions  and  for  myoma.  In  one  patient  the  flushing 
began  three  days  after  the  operation  ;  in  most  cases  it  is 
delayed  some  months,  and  in  a  few  the  flushes  are  not 
frequent  until  a  year  has  elapsed. 

In  one  patient  the  flushes  recurred  ten  times  an 
hour,  and  this  went  on  for  several  months.  In  women 
between  twenty  and  thirty  the  flush  is,  as  a  rule,  very 
mild  even  Avhen  frequent. 

My  observations  induce  me  to  believe  that  they 
are  more  severe  after  hysterectomy  in  women  between 
the  fortieth  and  fiftieth  years.  After  this  operation  there 
is  another  very  remarkable  condition  which  other 
surgeons  must  have  observed ;  it  is  this  : — On  comparing 
a  number  of  temperature  charts,  it  will  be  seen  that  in 
many  there  will  be  found  a  very  sudden  rise  of  tempera- 
ture;  sometimes  it  will  reach  as  high  as  105°,  usually  it 
is  103°  or  104°.  When  this  occurs,  the  surgeons  may 
feel  that  something  is  wrong  with  the  patient,  yet  she 
will  appear  comfortable,  and  her  general  condition  is 
not  consonant  with  the  temperature  record.  When 
this  is  the  case,  a  cautious    inquiry   will    show  that  the 


Summary.  487 

day  on  which  the  temperature  rose,  according  to  the 
patient's  reckoning,  would  be  the  date  on  which  she 
would  in  the  ordinary  way  expect  to  menstruate.  I 
have  tested  this  often  in  my  patients  and  in  those  ot 
other  surgeons.  Knowledge  of  this  fact  has  on  several 
occasions  spared  me  much  anxiety. 

With  regard  to  treatment,  I  know  of  no  drugs  which 
have  any  effect  in  preventing  or  in  any  way  diminishing 
the  force  and  frequency  of  the  flushes.  I  have  tried 
many,  but  now  adopt  no  form  of  treatment,  but  endeavour 
to  comfort  the  patients  by  the  assurance  that  the 
vaso-motor  storms  will  slowly  diminish,  until  they  cease 
to  be  even  inconvenient. 

The  influence  of  the  removal  of  both  ovaries  from 
a  sexually  mature  woman  upon  the  sexual  appetite  and 
nubility  I  do  not  propose  to  consider.  This  question 
has  been  discussed  by  other  writers. 

The  subject  matter  of  this  chapter  may  be  sum- 
marised thus  : — 

1.  There  is  no  evidence  that  double  ovariotomy  and 

oophorectomy  lead  to  any  unusual  development 
of  the  secondary  sexual  characters. 

2.  There    is  no    evidence    that   such  operations  in- 

duce atrophy  of  the  breast,  but  they  may  cause 
obesity  in  women  who  have  a  tendency  to  form 
fat. 

3.  With  extremely    rare  exceptions,  menstruation  is 

permanently  arrested :  irregular  haemorrhages 
may  follow  the  operation,  due  to  irritation 
caused  by  ligatures,  submucous  tumours,  or 
other  uterine  disease.  Such  must  not  be  con- 
founded with  menstruation. 

4.  In   most,  the   sexual  appetite  is  unaffected,  in   a 

few  destroyed,  but  in  many  it  is  restored. 

5.  A  third  ovary  has  yet  to  be  demonstrated. 


488-  Ovarian  AND  Tubal  Diseases. 

6.  A  careful  study  of  the  question  leads  me  to  sub- 
scribe to  the  opinion  of  Tissier*  that.  "  Le  cas 
ancien  de  Pott,  oil  la  castratmi  fut  suivre  de 
7nodifications  de  V habitus  exterieure,  de  la  voix, 
du  volume  des  sei?is,  est  reste  presque  isole" 

*  Delbet  :  Des   Suppurations  pdviennes  chez    la  Fenime,    p.    338  ; 
Paris,  1 89 1. 


INDEX     TO     NAMES. 


Altormyan,  185 
Anderson,  121 
Atlee,  221,  479 
Aveling,  208 

B 

Bagot,  74  ' 

Ballantyne,  229,  274 
Bantock,  59,  65,  176,  196,  205 
Barnes,    Robert,    29,    156,    170, 

291,  348,  370,  375 
Beaumont,  155 
Beck,  159 
Beigel,  22 
Blackman,  130 
Bouchard,  279 
Bozeman,  380 
Bright,  155,  170 
Brodie,  Sir  B.,  130 

,  G.,  267 

Brown,  Baker,  474 
Bryant,  185 
By  ford,  461 

C 

Campbell,  485 
Carter,  76,  196 
Chahbazain,  402 
Chambers,  25,  476 
Champneys,  t,-],  346,  424,  481 
Clegg,  403 
Coblenz,  94 

F  F* 


Collins,  Treacher,  76 
Cooke,  364 
Copeman,  20 
Coupland,  79 
Croom,  II.,  137 

Cullingworth,   67,   75,  83,    188, 
222 

D 

Daly,  402 

Darwin,  4 
Delbet,  292 
Dezeimeris,  324 
Doleris,  284 

Doran,  17,  23,  33,  71,  84,  98, 
127,  131,  160,  261,  280,   350, 

474 
Dreschfeld,  75 
Duncan,  Matthews,  15,   35,  69, 

153,  167,  204,  383 

E 

Edwards,  136 
Emmet,  197       . 
Ercolani,  390 
Ewens,  68 

F 
Fagge,  161 

Farre,  10,  13,  225,  4S0 
Fetherston,  196 
Fleming,  391 
Fortescue,  461 
Fowler,  249,  261 
Franck,  25 


490         Diseases  of  the  Ovaries^  etc. 


Freeman,  47,  295 

Klob,  135 

Freund,  1S6 

Koeberle,  92 

G 

Kolaczek,  70 

Galabin,  25,  200,  365 

Kussmaul,  354 

Gervis,  ^jy 

L 

Godson,  298,  413 

Langton,  27 

Goodall-Copestake,  196 

0             '         / 

Lee,  461 

Goodell,  222,  365 

7    ~r 

,  T.  Safford,  152,  171 

Goodhart,  29 

Leon,  Mendes  de,  196 

Gooding,  197 

Lepine,  279 

Goupil,  329,  399 

Lewers,  261 

Gray,  66 

Lizars,  171 

Griffith,  III,  119,  211,  277 

Lucas,  479 

Grigg,  292 

Luschka,  357 

H 

Hamilton,  392 

M 

Hart,  337 

Macdonald,  362 

Henry,  161 

Mackenzie,  19 

Herman,    131,    320,    367,    401, 

Manser,  131 

426 

Martineau,  152 

Hicks,  348,  367 

Mason,  462 

Hillas,  461 

McClintock,  174 

Holland,  464. 

McDowell,  474 

Hudson,  81 

Mead,  152 

Hulke,  28,  80 

Meredith,  150,  194,  305,  469 

Hurry,  298 

Metschnikoff,  243 

Hutchinson,  387,  474 

Moore,  69 

Hyrth,  307 

,  Milner,  192 

J 

Morris,  H.,  158,  192,  256 

Moxon,  193 

Jessop,  90,  345 

Munde,  57,  161,  484 

Jones,  17 

K 

Murchison,  154 

Keith,  S.,  258,  415 

Murray,  144 

,   T.,  216,   222,    305,    441, 

Myrtle,  480 

458 

N 

Kelly,  483 

Noeggerath,  484 

Kidd,  272 

Neumann,  66 

Index. 


491 


O 

Olshausen,  22,  153,  465,  479 


Page,  1 98 
Paget,  Sir  J.,  303 

,  Stephen,  466 

Parry,  14,  325,  335,  366,  370 

Patenko,  16 

Peaslee,  479 

Playfair,  305 

Pollock,  462 

Popow,  14 

Pott,  475 

Potter,  69 

Poupinel,  49 

Pozzi,  460 

R 

Rasch,  195 
Reeves,  53,  73,  175 
Ricard,  161 
Richard,  iii,  224 
Ritchie,  14 
Robinson,  117 
Rokitansky,  15,  135,  193 
Roper,  403 
Routh,  362 
Rowan,  370 
Ruffer,  243 


Sale,  364 
Sanger,  203 
Schneidemiihl,  118 
Shattock,  58,  67,  77 


Sheild,  342 
Silcock,  272 
Simmonds,  3S7 
Simpson,  286,  360 
Sippel,  219 
Smith,  Greig,  140 

,  PL,  29 

,  Nathan,  474 

J  Tyler,  367 

Spaeth,  286 
Stevenson,  414 
Stewart,  375 
Stonham,  25,  378 
Sutton,  Stansbur}-,  474 


Tait,  Lawson,  13,  135,  145,  167, 
194,  325,  344,  368,  397,  474 

Taylor,  72,  347 

Thornton,  67,  126,  135,  139, 
15S,  415,  46S,  4S0 

Tissier,  487 

Treves,  158 

Turner,  357 


V 


Veit,  258 
Velits,  61 
Virchow,  357 
Vocke,  291 


W 


Walter,  108,  113,  28 1 

Ward,  O.,  217 

Wells,    Sir    S.,    74,    137,     144, 

159,  172,  194,  204,  246.  305, 

460,  465,  470 


492 


Diseases  of  the  Ovaries^  etc. 


Wheaton,  275 

Wilks,  193 

Williams,  229,  274 

Williams,  J.,  6,  25,  71,  201,  415 

Wilson,  365,  464 

Wiltshire,  144,  156 


Winckel,  22,  83 
Worrall,  379 

\ 

Yarrow,  178 

Z 

Zemann,  278 


INDEX     TO     SUBJECTS. 


Abortion,  tubal,  326 
Abscess  of  ovary,  276 
,,       of  pedicle,  474 
,,       tubo-ovarian,  251,  260 
Absence  of  ovary,  22 
Accessory  fimbriae,  227 
,,         ostia,  225 
,,         ovaries,  22 
Actinomycosis  of  the  tube,  278 
Adenoma   of    the    cervix   uteri, 

265 

5  9  J>  5  5  iri 

monkeys,  267 
,,       of  the  ovaries,  52 
Adhesions,  132 

,,  treatment  of,  433    . 

, ,  of  vermiform  appen- 

dix, 127 
Aggressive  cells,  243 
Air  in  ovarian  cysts,  154 
Allantoic  cysts,  209 
Amoebic  warfare,  243 
Antlered  does,  478 
Apoplexy  of  the  ovary,  16 
Atrophy  of  the  ovary,  33 


Axial  rotation,  135 

,,  ,,         of    a     hydrosal- 

pinx, 256 
,,  ,,         of  ovarian  cysts, 

135 
,,  ,5         of        parovarian 

cysts,  108 
B 
Bladder,  distended,   199 

,,         forceps  in,  after  ovari- 
otomy, 465 
, ,        injury  to,  in  ovariotomy, 

459 
,,       relations  of,  42 
Blushing,  morbid,  485 
Broad  ligament,  anatomy  of,  36 
,,  ,,  hydatids     of, 

186 
,,  ,,  tumours     of, 

203 
C 
Cancer  and  pyosalpinx,  249 
Carcinoma  of  the  ovary,  76 

55  55       primary,  76 

,,  ,,         secondary, 

79 


Index. 


493 


Cave  of  Retzius,  38,  211 
Children,  extra-uterine,  423 
Cicatrix  after  ovariotomy,  445 
Colloidknittern,  153 
Concretions  in  the  ovary,  19 
Corpora  fibrosa,  16 
Corpus  UUeum,  14 

,,  ,,       cysts  of,  15 

Cysts,  allantoic,  209 

dermoid,  57 

hydatid,  183 

oophoritic,  45 

papillomatous,  95 

paroophoritic,  93 

parovarian,  104 

renal,  190 

urachus,  209 

D 

Decidua,  menstrual,  336 

,,  in     tubal    pregnancy, 

335 
„  uterine,  336 

Dermoids,  ovarian,  57 
,,  bone  in,  58 

,,  glands  of,  58 

,,  hair  of,  57 

,,  horn  in,  61 

,,  in  infants,  89 

,,  mammae  in,  58 

,,  metastasis  in,  70 

,,  mucous       membrane 

in,  48 
,,  muscle-fibre  in,  58 

,,  nerves  in,  64 

,,  suppurating,  131 

,,.         teeth  in,  d-^ 


Diagnosis   of    ovarian    tumours, 

163 

,,         of  salpingitis,  289 
,,        of    tubal   pregnancy, 

397 
Double-fused  ovarian  cysts,  148, 

434,  437 
Drainage,  454 

,,         advantages  of,  458 
,,         disadvantages  of,  457 
,,         indications  for,  457 
,,         mode  of  carrying  out, 

455 
tubes,  455 
„  ,,       Keith's,  455 

,,  „       Koeberle's,  455 

E 

Epithelial  pearls,  63 
Epithelium  in  oophoritic  cysts, 

50 

,,  in  parovarian  cysts, 

no 
,,  in     tubal     disease, 

309 
Erosion  of  os  uteri  in  monkeys, 
268 
,,  ,,        in  w^omen, 

266 
F 
Fallopian  tube,  anatomy  of,  223 
,,  adenoma  of,  280 

,,  cancer  of,  287 

,,  glands  of,  230 

,,  gumma  of,  279 

,,  inflammation  of, 

235.     {See  Salpingitis.) 


494 


Diseases  of  the  Ovaries^  etc. 


Fallopian  tube,  myoma  of,  286 
,,  mucous       mem- 

brane of,  229 
,,  ostium  of,  224 

, ,  papilloma  of,  280 

,,  tuberculosis  of,  272 

Fibroma  of  the  ovary,  71 
Flushes,  485 
Flushing   the    peritoneum,    452 

{See  Irrigation.) 
Fcetus,  macerated,  376,  426 
,,         mummified,  344,  372 
,,         retained,  372 
sj  ,,        in  cat,  392 

,,  ,,        in  cow,  385 

»,  ,,        in  ewe,  388 

.J  J 5        in  guinea-pig, 

391 
J,  ,,        in  hare,  387 

J.  ,,        in  jackal,  393 

Foreign  bodies  left  in  abdomen, 
464 

G 

Gestation,  abdominal,  344 

broad  ligament,  324 
cornual,  354 
ovarian,  332 
peritoneal,  344 
tubo-uterine,  349 

H 

Hcematocele,  399 

,,  ovarian,  332 

Hsematoma,  317 
Hsematosalpinx,  262 
Hernia  of  the  ovary,  24 

J)  ,,     treatment  of, 

303 


Hydatid  cysts,  183 

.,  ,,     of  the  broad  liga- 

ment, 186 
,,         ,,     of  the  liver,  185 
,,  ,,     of  the  mesentery, 

196 
,,         ,,     of  the  omentum, 

196 
,,         ,,     of  the  ovary,  184 
,,         ,,     of  the  uterus,  185 
,,       fremitus,  183 
,,       of  Morgagni,  227 
Hydramnios,  174 
Hydrocele, ovarian,  in,  260 
,,  „  in  guinea-pig,  1 19 

,,  ,,  intermitting,  121 

,,  J  5  in  mare,  118 

,,  ,,  in  women,  ill, 

120 
Hydrometra,  182,  247 
,,  in  ewe,  247 

,,  in  women,  246 

Hydronephrosis     and      ovarian 
cysts,  190 
,,  intermitting,  192 

Hydroperitoneum   in  tubal  dis- 
ease, 261 
Hydrops  tubas  profluens,  I2I 
Hydrosalpinx,  252,  259 

,,  causes  of,  256 

,,  intermitting,  258 

,,  rotation  of,  257 


Infundibulum,  223 
Intestinal  obstruction  from  ova- 
rian cysts,  161 


Index. 


495 


Intestinal  obstruction  after  ova- 
riotomy, 468 

Irrigation,  452 

,,'        indications  for,  452 
,,         method  of,  452 

K 

Kidney,  congenital  cystic,  190 
,,        in    hollow    of  sacrum, 

191 
,,        movable,  190 

L 

Ligament,  broad,  36 

,,  round,  38 

,,  tubo-ovarian,  224 

,,  utero-sacral,  39 

Ligature,  absorption  of,  474 

,,        fate  of,  472 

,,        history,  474 

,,        mode  of  applying,  434 
Lithopaedion,  373 

M 

Macaques,    menstruation   in,    7, 
267 

Macrophages,  243 

.Menopause,  artificial,  447 

Menstruation,  5 

,,  in  monkeys,  7 

, ,  in  women,  5 

Mesometrium.      {See  Broad  liga- 
ment.) 

Mesosalpinx,  38 

,,  crumpling  of,  240 

,,  infiltration  of,  240 

,,  obliteration  of,  238 

Metrostaxis,  444 


Micro-organisms,  243 
Microphages,  243 
Moles,  tubal,  314 

,,      uterine,  315 
Monkeys,  adenoma  of  cervix  in, 
269 
,,        leucorrhoea  in,  270 
,,         menstruation  in,  7, 267 
Morgagni,  hydatid  of,  227 
Myoma  of  broad  ligament,  203 
,,       of  ovarian  ligament,  209 
,,       of  ovary,  72 
,,      of  round  ligament,  203 
,,       of  uterus,  179 

N 
Nerves  in  dermoids,  65 
Nerve-storms,  485 
Neurotic    affections,    operations 

for,  304 

O 
Qistrus,  10 

Oophorectomy,  447 

,,  mode  of  perform- 

ing, 448 
„  mortality  of,  305 

Oophoromata,  91 
Oophoron,  definition  of,  44 

,,  cysts  of,  45 

Ostium,  accessory,  225 
,,         occlusion  of,  236 

in      tubal 
pregnancy,  312 
,,         tubal,  224 
Ovarian  cysts,  diagnosis,  163 
,,  from  ascites,  166 

,,  from     broad    liga- 

ment tumours, 203 


496 


Diseases  of  the  O'^ar/es,  etc. 


.Ovaria 


1   cysts  from  chyle-cysts, 

195 
from        distended 

bladder,  199 

from  foscal  accu- 
mulations, 199 

from  fatty  tumours, 
194 

from  gall-bladder, 
194 

from  hydatid  cysts, 
196 

from  hydramnios, 

174 

from  hydrometra, 
182 

from  hydrone- 
phrosis, 158 

from  liver,  en- 
larged, 195 

from  mesenteric 
tumours,  196 

from  myoma  of 
broad  ligament,  203 

from  myoma  of 
round  ligament,  203 

from  myoma  of 
uterus,  179 

from  obesity,  200 

from  omental 
cysts,  196 

from  omental  hy- 
datids, 196 

from  pancreatic 
cysts,  194 

from  pelvic  cellu- 
litis, 210 


Ovarian  cysts  from  perica'cal 
abscess,  213 

,,  from      peritonitis, 

tubercular,  167 

,,  from  phantom  tu- 

mour, 170 

,,  from  physometra, 

178 

, ,  from     pregnancy, 

tubal,  412,  414 

,,  from     pregnancy, 

uterine,  172 

,,  from      post -rectal 

dermoids,  198 

,,  from     sacral     tu- 

mours, 197 

,,  from  serous  peri- 

metritis, 201 

.,  from  spina  bifida, 

197 

,,  from  spleen,  193 

,,  adhesions  of,  132, 

433 

,,  air  in,  154 

,,  detachment  of,  140 

,,  diagnosis  of,  163 

,,  inflammation     of, 

123 
,,  intestinal  obstruc- 

tion from,  161 
,,  leakage  from,  147 

,,  necrosis  of,  138 

,,  pressure     eftects, 

147 
,,  rotation  of,  135 

,,  rupture  of,  147 

„  suppuration  of,  1 28 


Index. 


497 


Ovarian  cysts,  torsion  of,  135 

,,  treatment  of,  214 

,,  varieties  of,  44 

Ovarian  gestation,  332 
,,       hsematocele,  332 
,,       hydrocele     in     guinea- 

pig>  1^9* 
,,  ,,         in  the  mare, 

118 
,,  ,,         in      women, 

III 
Ovarian  mamnix,  58 

.,  ,,         areola  of,  58 

,,  ,,         nipples  of,  59 

,,  ,,         structure  of,  61 

,,        pseudo-mammce,  58 
Ovarian  sac  in  baboons,  116 
,,  in  hysena,  115 

,,  in  porcupine,  117 

,,  in   rats    and    mice, 

115 

,,  in  women,  114 

Ovarian  teeth,  63 

,,  development    of, 

63 
,,  nerves  in,  64 

,,  structure  of,  65 

,,  varieties  of,  63 

Ovaries,  abscess  of,  276 
„         absence  of,  22 
,,         accessory,  22 
,,         apoplexy  of,  16 
,,         atrophy  of,  33 
,,         cancer  of,  76 
,,         concretions  in,  19 
,,         dermoids  of,  57 
,,         fibroma,  71 


Ovaries,  hernia  of,  24 

hydatids  of,  184 
malformation  of,  22 
melanosis  of,  79 
misplacement,  23 
myoma,  72 
sarcoma  of,  74 
secondary  cancer  of,  78 
solid  tumours  of,  71 
tuberculosis  of,  272 
Ovariotomy,  anaisthesia  in,  430 
,,         cystitis  after,  443 
,,         in    advanced    life, 

220 
,,         in  children,  87,  221 
,,         incomplete,  441 
„         in  pregnancy,  217 
„         in         suppurating 

-  cysts,  215 
,,         mode  of   perform- 
ing, 428 
,,         mortality  of,  222 
,,         repeated,  471 
„         risks  of,  459 
,,  ,,        embolism, 

468 
,,  ,,        erysipelas, 

445 
,,     forceps,  465 
,,  ,,  haemorrhage, 

462 
,,  „    insanity,  467 

,,  ,,  intestinal  ob- 

struction, 468 
,,  ,,   parotitis,  466 

„  ,,    peritonitis, 

463 


498 


Diseases  of  the  Ovar/es,  etc. 


Ovariotomy,  risks  of  shock,  459 
,,  ,,        sponges, 

464 
,,  ,,        yielding 

cicatrix,  445 
,,         the  incision,  430 
„         triple,  472 
,,         treatment  after,  442 
Ovulation,  10 

Ovum,  apoplectic.     [See  Tubal 
mole.) 


Pain,  pelvic,  300 
Pampiniform  plexus,  42 
Papillary  cysts,  99 
Papillomata,  96 
Papillomatous  cysts,  95 

,,  infection,  98 

Parametritis,  210 
Paroophoritic  cysts,  93 

,,  ,,        burrowing 

of,  93- 
,,  ,,         characters 

of,  93 
,,  ,,        rupture  of, 

98 
Paroophoron,  3 
Parovarian  cysts,  104 

,,  ,,       characters   of? 

106 
,,  ,,        epithelium  of, 

no 
,,  ,,       iluid  in,  107 

,,  ,,       rotation       of, 

108,  136 
,,  ,,       rupture  of,  150 


Parovarian  cysts,  tapping  of,  151 
I'arovarium,  the,  3,  104 
Pedicle,  abscess  in,  474 
,,        anatomy  of,  434 
,,        cauterising  the,  438 
,,        double,  437 
*  „        ligature  of,  434 
,,        mode  of  tying,  435 
,,        sloughing  of,  473 
Pelvic  cellulitis,  210 

,,  peritoneum,  36 
Pericoecal  abscess,  213 
Perimetritis,  210 

,,  serous,   201 

Perioophoritis,  35 
Peritoneum,  pelvic,  36 
Pregnancy  and  ovarian  cyst,  177 
,,  cornual,  354,  413 

,,  extra-uterine.       {See 

Tubal  pregnancy.) 
Puberty,  4 
Pyosalpinx,  244,  252 

,,  causes,  244 

,,  in   uterine    cancer, 

249 
,,  symptoms,  293 

,,  treatment,  302 

puberty,  4 
Placenta,  tubal,  333 

,,  ,,    migration  of,  337 

,,  ,,    structure  of,  337 

,,  ,,    treatment  of,  421 

Pouch,  Douglas',  36 

,,  ,,       diverticulum     of, 

2,1,  153 
,,  ,,       recto- vaginal,  t,6 

,,  ,,       utero-vesical,  37 


Index. 


499 


R 

Recto-vaginal  pouch,  37 

Rotation  of  cysts,  135 

,,  ,,       acute,  140 

„  „       causes  of,  135 

,,  ,,       chronic,  140 

,,  ,,       effects  of,  137 

,,  ,,       symptoms,  142 

,,  ,,       treatment,  144 

,,         of  the  spleen,  193 
,,         of  uterus  in  cow,  387 
„  .      „        in  ewe,  389 

„  „         in  guinea-pig, 

391 
„  ,,        in  hare,  387 

Rupture  of  gestation  sac,  321 
„  „  ,,  primary,  321 

„  „  ,,  extra  -  peri- 

toneal, 323 
,,  „  ,,  intra  -  peri  - 

toneal,  322 
„  ,,  ,,  secondary, 

343 
„  „  „  extra  -  peri  - 

toneal,  344 
„  „  „  intra  -  peri  - 

toneal,  343 
„  M  J,  signs,   of, 

417 
,,  ,,  ,,  treatment, 

416 
„       of  ovarian  cysts,  147 

^  J  j^  ^9  C3.  Vises 

of,  147 
„  „  „         into  hol- 

low   vis- 
cera, 154 


Rupture  of  ovarian  cysts,  signs 
of,  151 
,,  ,,  ,,         spon- 

taneous, 147 
,,  ,,  ,,         trau- 

matic, 155 
,,        of  uterus  in  a  cat,  392 
„  „       in  a  hare,  387 

„  „       in  a  jackal,  393 

Rut,  12 

S 
Salpingitis,  235 

,,  catarrhal,  265 

,,  cell  changes  in,  241 

,,  diagnosis  of,  289 

,,  gonorrheal,  235 

,,  in  harridans,  255 

,,  septic,  235 

,,  treatment  of,  301 

,,  tubercular,  272 

Salpingostomy,  451 
Sarcoma,  ovarian,  74 

,,        in  children,  87 
vSarcomata  in  dermoids,  90 
Sex,  I 
Sexual  characters,  i 

,,  ,,  primary,  I 

,,  ,,  secondary,    3, 

475 
glands,  I 
,,  ,,        effects    of    their 

removal,  475 
Spleen,  193 

,,       enlargement  of,  194 
,,       rotation  of,  193 
,,       transposition  of,  193 
,,       wandering,  193 


t;oo 


J^fSEASES    OF    THE    Ov ARIES,    ETC. 


Strumpets,  sterility  of,  263 
Supernumerary  ovary,  22 
Suppuration  in  ovarian  cysts,  128 

^9  J  9  J )   C3. Vises 

of,  124 
•;,  from     appendicitis, 

127 
,,  from  intestinal 

gases,  127 
,,  from  salpingitis,  124 

T 

Tapping  ovarian  cysts,  214 

,,         parovarian  cysts,  151 
Treatment  of  ovarian  cysts,  214 
,,         of  parovarian  cysts, 

214 
,,         of  salpingitis,  301 
,,         of  tubal  pregnancy, 
416. 
Tubal  abortion,  326 

„  ,,         signs  of,  330 

,,  ,,         treatment  of,  33 1 

,,     moles,  314 

,,         ,,       characters  of,  319 

,,     pregnancy,  307 

,,  ,,  causes  of,  30S 

,,  ,,  diagnosis      of, 

396 
,,  ,,  treatment      of, 

416 
,,  ,,  twins  in,  369 

,,  ,,  varieties  of,  321 

Tuberculosis   of    the    Fallopian 
tube,  272 
, ,  of  the  ovary,  276 


Tuberculosis,  signs  of,  278 

,,  treatment  of,  303 

Tubo-ovarian  abscess,  251,  260 

cyst,  259 
Tubo-uterine  gestation,  348 
Tubules,  Kobelt's,  104 
,,         parovarian,  104 

U 

Urachus,  cysts  of,  209 
Ureters,  43 

,,         injury  to,  133,419,460 
Utero-sacral  ligament,  39 
Utero- vesical  pouch,  37 
Uterus,  adenoma  of,  265 

bicornuate,  37,  247,354, 

413 
,,        broad  ligament  of,  36 
,,        retroflexion  of,  297 
,,        retroversion  of,  29S,  413 
,,        round  ligament  of,  38 
,,        unicorn,  355 
,,        watery  discharges  from, 

258,  284 

\^ 
Vaso-motor  disturbances,  485 
Mlli,  chorionic,  320 

„  ,,  significance   of, 

320 
,,  ,,  structure  of,  320 

\^omiting,  after  ovariotomy,  442 

W 

Wart's  in  paroophoritic  cysts,  93 
„       in  parovarian  cysts,  iio 
„       on  ovaries,  100 
„       on  peritoneum,  98 


Printed  pa'  Cassell  &  Company,  Limited,  La  Belle  Sauvage,  London,  E.C. 


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Surgical  d  seases  of  the  ovaries  and  Fal 


2002281244 


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